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THE 



CYCLOP^Dl.1 



PRACTICAL MEDICINE 



VOL. II. 



THE 



CYCLOPEDIA 



OF 



PRACTICAL MEDICINE: 



COMPRISING 

TREATISES ON THE NATURE AND TREATMNT OF DISEASES, MATERIA MEDICA 
AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC., ETC. 

EDITED BY 

JOHN FORBES, M.D. F.R.S. 

PHYSICIAN TO THE QUEEN's HOUSEHOLD, ETC. 

ALEXANDER TWEEDIE, M.D. F.R.S. 

PHYSICIAN TO THE LONDON FEVEP. HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC. 

JOHN CONOLLY, M.D. 

LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO 
THE HANWELL LUNATIC ASYLUM, ETC. 

THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY 

ROBLEY DUNGLISON, M.D. 

PROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, 
LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. 



" Hffic demum sunt quas non subgessit phantasiae imaginatricis tcmeritas sed phfenomena practica 
edocuere," — Sydenham. 



IN FOUR VOLUMES. 
VOL. II. 

EMPHYSEMA — INFLAMMATION. 




LIBRARY 
surfstof; G£:*:r;AL's office 



PHILADELPHIA; 
BLANCHARD AND LEA, 

1859. 









Entered, according to Act of Congress, in the year 1845, by 

LEA AND BLANCHARD, 

in the clerk's office of the District Court of the United States for the Eastern District 



of Pennsylvania. 



FAGAN, STEREOTYPER. 



COLLINS, PRINTER 



1>S 



^5 



^ 



CONTENTS OF THE SECOND VOLUME. 



Enteritis. 



46 



Contributurs. Page 

Emphysema Dr. Townsend .... 9 

Emphysema of theLungs Townsend.... 17 

Empyema Townsend.... 21 

Endemic Diseases Hancock 39 

C Stokes .... 

(_ Dunglison , 

Ephelis Todd 62 

Epidemics Hancock 64 

Epilepsy Cheyne 75 

Epistaxis Kerr 91 

Erejthismus Mercurialis Burder 96 

Erysipelas Tweedie 96 

Erythema Jot/ 105 

Eutrophic Dunglison .... 1 1 1 

Exanthemata , Tweedie 112 

Expectorants A. T. Thomson 112 



Expectoration 
Favus 



Feigned Diseases .. 



Williams 119 

A. T. Thomson 123 

Scott -\ 

Forbes C 123 

Marshall ...j 

Tweedie 147 

Tweedie 153 

Tweedie 162 

Cheyne 201 

Brown 205 

Brown 219 



Fever 

" Continued 

" Typhus 

«< Epidemic Gastric 

" Intermittent 

« Remittent 

" Malignant Remit- 
tent Dunglison 

" Infantile Remittent 

" Hectic 

" Puerperal 

" Yellow 

Fungus Hsematodes... . 



Galvanism 



Gastritis 

Gastrodynia 

Gastro-enteritis 

Glanders Dunglison 

Glossitis Kerr . ... 



.223 

Joy 224 

Brown 229 

Lee 231 

Gillkrest 247 

Kerr 280 

Apjohn 
Dunglison , 

Stokes 298 

Barlow 307 

Stokes 314 

323 
325 



nV.] 



285 



Glottis, Spasm of the . 
Gout 



Joy 329 

Barlow 332 



85 



.391 
.391 



Contributors. Page 

Haematemesis Dr. Goldie 357 

Hsemoptysis Law 362 

H^adach Burder 371 

Heart, Diseases of the. . Hope 377 

" Dilatationof the. . Hope 379 

" Displacement of 

the Townsend , 

" Fatty and greasy de- 
generations of the Hope 

" Hypertrophy of the Hope .... 

" Malformations of 

the ". Williams 404 

" Polypus of the . . Dunglison ... .409 

" Rupture of the . . Townsend 410 

« Diseases of the 

valves of the . . . Hope 414 

Hemorrhage Watson 430 

Hemorrhoids ........... Burns ... 438 

Hereditary Transmission 

of Disease Brown 443 

Herpes A.T. Thomson 445 

Hiccup Ash 450 

Hooping-Cough Johnson 453 

Hydatids Kerr 459 

Hydrocephalus Joy 476 

Hydropericardium Darwall 502 

Hydrophobia Burdsley 506 

Hydrothorax Darwall 538 

Hyperaesthesia Dunglison 543 

Hypertrophy Townsend .... 543 

Hypochondriasis Prichard 554 

Hysteria Conolly 562 

Ichthyosis A.T. Thomson 589 

Identity Montgomery ..591 

Impetigo A.T. Thomson 594 

Impotence Beatty 597 



Incubus 
Indigestion .., 
Induration . . 
Infanticide . . . 
Infection . . . , 

Inflammation 



Williams 606 

Todd 608 

Carswell 666 

Arrowsmith. . .677 

Brown 693 

Crawford. 
Tweedie. 

(5) 



B 



694 



IHK 



CYCLOPEDIA 



PRACTICAL MEDICINE. 



EMPHYSEMA. — This term, derived from 
the Greek verb iiicpvijdo}, to inflate, is used in 
medical language to signify the presence of air in 
the cellular tissue. 

The portion of the cellular tissue which is most 
frequently affected with emphysema is the subcu- 
taneous ; but as all the prolongations of this tissue 
throughout the body are directly continuous, and 
communicate freely by their areola structure, the 
air in emphysema, when once effused in any part 
of it, may extend wherever cellular tissue exists. 

Frank remarks that thin persons are more liable 
to emphysema than those whose cellular tissue is 
loaded with fot; and it is matter of common ob- 
servation, that those parts of the body where the 
cellular tissue is lax and free from fat are most 
easily affected with this disease. Thus, the eye- 
lids, scrotum, neck, and sides of the thorax, yield 
readily to the admission of air, while the buttocks 
and thighs, the arms and legs are much more 
slowly distended. The dense cellular tissue which 
lines the serous and mucous membranes yields 
with still more difficulty to emphysema, and the 
palms of the hands and soles of the feet are among 
the last parts to become so affected. 

There are two modes in which emphysema 
may be produced : 1. by the introduction of 
atmospheric air into the cellular tissue through a 
solution of its continuity ; or, 2. by the develop- 
ment of gas within the cells of the part. The 
former is termed traumatic, the latter idiopathic 
or spontaneous emphysema. 

Traumatic emphysema is of much more fre- 
quent occurrence than the idiopathic species. It 
may succeed to any wound of the integuments 
which allows the external air to get into the sub- 
jacent cellular tissue ; but in a great majority of 
cases, (amounting to ninety-nine out of the hun- 
dred,) it arises from the introduction of air into 
the common cellular tissue through a communi- 
cation formed more or less directly with the organs 
of respiration. The following are the principal 
ways in which this communication may be estab- 
lished. 1. By wounds or ulcers communicating 
with the interior of the mouth or nares. 2. By 
perforation of the larynx or trachea. 3. By rup- 
ture of the- air-cells and interlobular cellular tis- 
sue, the investing membrane or pleura remaining 
uniiijurcd, and the air escaping through the roots 
of the lungs and mediastinum into the general 
cellular rissuc. 4. By perforation of the lung, 
pleura pulmonalis, and pleura costalis. 5. By 

Vol. II. — 2 



penetrating wounds of the chest, the lung and its 
investing membrane remaining uninjured. 

1. Wounds or ulcers communicating with the 
interior of the mouth or nares. — Frank states that 
emphysema is not unfrequently produced in per- 
sons learning to play on the flute, or other wind 
instruments, in consequence of the air being forced 
into the parietes of the cheek through any wound 
or small ulcer which may happen to exist on its 
internal surface, (De curand. hom. morbis : Art. 
Pneumatosis.) And M. Rullier informs us that 
the prisoners in the Bicetre at Paris, when they 
wished to be transferred to the infirmary, were in 
the habit of producing an artificial emphysema 
of the face and throat, by puncturing the inside 
of the cheek with a pin, and then forcing the 
breath through the puncture, (Diet, de Medecine, 
Art. Emphyseme.) In wounds of the under-eye- 
lid communicating with the lachrymal sac, em- 
physema is not a very uncommon occurrence, the 
air passing from the nares, through the duct, into 
the sac, and thence finding its way into the lax 
cellular tissue in the neighbourhood : in like man- 
ner emphysema of the head and face has been 
observed to take place in cases of fracture of the 
frontal bone communicating with the interior of 
the nares. 

2. Perforation of the larynx o. trachea. — In 
wounds of the larynx or trachea, part of the air 
which is expelled from the lungs at each expira- 
tion, instead of passing through the glottis, escapes 
through the wound ; but if its free exit is opposed 
by the narrowness or obliquity of the external 
orifice, instead of passing out directly, it insinu- 
ates itself into the areolae of the cellular tissue, 
forming an emphysematous swelling round the 
wound, and from thence extending all over the 
body. Instances have also occurred, where, from 
a severe blow, some of the rings of the trachea 
have been ruptured ; and the same effect has been 
said to arise from coughing. We are not acquaint 
ed with the records of any case in which perto 
rating ulcers of the larynx or trachea have led to 
the formation of emphysema ; a fact which is pro- 
bably to be accounted for by the air being pre- 
vented from entering the cellular tissue by the 
adhesive inflammation which usually precedes 
and limits the ulcerative process. 

3. Rupture of the air-cells and interlobular eel 
lular tissue, the investing membrane or pleuia 
remaining uninjured, and the air escaping through 
the roots of the lung and mediastinum into the 

'9) 



10 



EMPHYSEMA. 



general cellular tissue. The rupture of the pari- 
etes of the air-cells formed by the ultimate rami- 
fications of the bronchi is by no means an un- 
common occurrence ; (see Emphysema of the 
Lungs ;) but so long as the cellular tissue which 
invests each lobule, and isolates it from those ad- 
joining, remains uninjured, the extravasated air 
is prevented from escaping beyond the lobule in 
which the ruptured air-cells are situated. When, 
however, the cellular tissue which invests each 
lobule, and which is in fact a prolongation or pro- 
cess of the general cellular tissue, of the body, is 
likewise lacerated, the air is then at liberty to en- 
ter the cells of that tissue which communicate one 
with another throughout the lung, and through 
the root of the lung and mediastinum, with the 
cellular tissue of the throat ; so that having once 
found its way from the ruptured air-cells into the 
interlobular cellular tissue, it passes uninterrupt- 
edly from cell to cell, (when urged forward by a 
sufficient force,) until it reaches the cellular tissue 
of the throat, where it makes its appearance in 
the form of an elastic crepitating tumour over one 
or both clavicles, and soon becomes diffused over 
the face and trunk. 

This variety of emphysema may be produced 
by violent fits of straining, coughing, or crying, 
or any other exertion of the respiratory organs, 
sufficiently powerful to rupture the air-cells and 
interlobular cellular tissue ; but it has been ob- 
served to occur most frequently in women during 
parturition, and in children severely affected with 
the hooping-cough. Dr. A. Hamilton, of Edin- 
burgh, observed a case of emphysema produced 
in this way by the efforts which a young woman 
made to conceal the pains of labour. She sud- 
denly lost her voice, and her face became swelled 
in a wonderful manner ; her respiration, too, be- 
came quick and laborious, and her pulse full and 
rapid. However, by rubbing the tumid parts 
twice in the day with camphorated oil, and tak- 
ing away a considerable quantity of blood from 
the arm, together with the use of laxative medi- 
cines, an<i an opiate at bed-time, the swelling be- 
gan to give way in the course of a week ; and in 
proportion as the emphysema disappeared, she 
recovered her voice. (Halliday on Emphysema.) 

Dr. Johnson, the learned professor of Midwife- 
ry in the Royal College of Surgeons of Dublin, 
informs us that six cases of this accident have 
occurred in his practice. In general the emphy- 
sematous swelling is confined to the neighbour- 
hood of the throat, where it first makes its appear- 
ance ; but in some cases it extends with a fi-ight- 
ful rapidity, and involves the entire surface of the 
body. In one case it extended to the very tips of 
the fingers. This form of emphysema is likewise 
occasionally produced by violent paroxysms of the 
hooping-cough. Dr. Johnson has known it to 
occur in three cases of this disease ; and Dr. 
Mackintosh of Edinburgh, and the late Dr. Beat- 
tie of Dublin, mentioned to us similar cases that 
had fallen under their observation. An interest- 
ing case of this form of emphysema is also record- 
ed by Dr. Ireland, in the third volume of the 
Dublin Transactions. — " A child nine years old 
was attacked with pneumonia. Under appropri- 
ate treatment the inflammatory symptoms seemed 
tn subside, but a severe cough remained behind, 



during a violent fit of which a colourless crepitat- 
ing swelling was observed to form above the cla- 
vicles, and extended rapidly until it spread over 
th^ whole body. The child died, apparently of 
sullocation, on the fifth day after the appearance 
of the emphysema." A case of emphysema of 
this kind is related by Louis, (Mem. de I'Acad. 
de Chir. t. iv,) which was produced by the efforts 
made to expel a bean that had fallen into the 
larynx. We have, however, had opportunities 
of observing that a fatal suffocation may be 
caused by the presence of a foreign body in the 
air-tubes, without necessarily producing this symp- 
tom. 

It is probable that many cases of emphysema 
supposed to be spontaneous are really produced in 
this manner. Thus, the emphysema which some- 
times appears on the sides of the thorax when 
much force is employed to reduce a dislocation of 
the humerus, probably arises from the escape of 
air in the manner we have described, through a 
rupture of the air-cells caused by the violent 
efforts which the patient makes to hold in his 
breath during the reduction of the dislocation. 
In like manner the emphysematous swellings 
which have been noticed by Frank, Cullen, and 
other practical writers, as occasionally occurring 
during the paroxysms of hysteria, may proceed 
from the air being forced through the cellular tis- 
sue of the lung and mediastinum, by the violent 
efforts at expiration which are made during the 
paroxysm, while the aperture of the glottis is kept 
spasmodically constricted. 

The great difficulty of breathing which occurs 
in this form of emphysema is sufficiently account- 
ed for by the distension of the lung, from the in- 
filtration of its interlobular tissue with air, and by 
the emphysematous swelling of the mediastinum. 

4. Perforation of the lung, pleura pulmonalis, 
and pleura costalis. This triple lesion may be 
produced — 1. by fracture of the ribs ; 2. by pene- 
trating wounds of the chest and lungs ; 3. by ul- 
ceration. As the emphysema which arises from 
the first two of these causes belongs more particu- 
larly to the province of surgery, we shall notice it 
very briefly, and refer the reader, who wishes for 
further details, to the works of surgical writers. 

There is no accident which so frequently gives 
rise to emphysema as fracture of the ribs; for 
when the sharp ends of the fractured bones pro- 
trude through the pleurae and lacerate the paren- 
chyma of the lung, the air passes freely through 
the bronchi into the sac of the pleura, and thence 
through the breach in the costal pleura into the 
subcutaneous cellular tissue, from whence it be- 
comes diffused all over the body, as there is no 
opening in the integuments through which it can 
escape externally. At each dilatation of the chest 
the air is sucked into the thorax through the la- 
cerated air-cells, and diffused uniformly over the 
surface of the lung, (supposing that no adhesions 
exist,) while at each effort of expiration the stra- 
tum of air contained within the pleura, being 
compressed by the contraction of the thoracic pa- 
rietes against the entire pulmonary surface, is pre- 
vented returning by the wound through which it 
had previously entered ; in this way the air con- 
tinues to accumulate within the sac of the pleura 
until it becomes so condensed, especially during 



EMPHYSEMA 



11 



the efforts of expiration, as to exert a very con- 
siderable degree of pressure on the parietes of the 
chest, and the important organs contained within 
it. The air tlien forces its way through the 
breach in the costal pleura made by the protru- 
sion of the fractured bone, and escapes into the 
cellular tissue on the outside of the thorax, 
whence it is rapidly diffused all over the body, a 
fresh supply of air being forced out at each expi- 
ration, so long as the wound in the lung con- 
tinues permeable. 

From this view of the mechanism by which 
emphysema is produced in the case of a fractured 
rib, it is evident that the escape of air into the 
cellular tissue, which has commonly been looked 
upon as the most dangerous part of the disease, 
should with more propriety be regarded as a fa- 
vourable circumstance, inasmuch as the air which 
escapes in this way would, if confined within the 
pleura, oppress not only the lung of that side 
where it is contained, but, by hindering the play 
of the diaphragm, and thrusting the mediastinum 
over into the opposite side, oppress the other lung 
also, and so produce great difficulty of breathing, 
or even a fatal suffocation. 

In the greater number of cases of emphysema 
arising from fracture of the ribs, the wound of the 
lung is soon closed by the effusion of blood, or by 
adhesive inflammation ; after which the further 
escape of air into the pleura ceases ; that already 
effused is promptly absorbed ; the respiration is 
no longer laborious ; the subcutaneous emphyse- 
ma ceases to extend, and in the course of a few 
days is removed by absorption. 

But in more severe cases the wound of the lung 
remains unclosed, and a fresh supply of air is 
pumped into the cellular tissue at each expiration, 
until the whole body becomes so distended as 
scarcely to retain a semblance of the human form. 
The following " History of an Emphysema," from 
the pen of Dr. WiUiam Hunter, is exceedingly 
characteristic of the appearances produced by ex- 
cessive distension of the subcutaneous cellular 
tissue, and of the peculiar difficulty of breathing 
caused by the pressure of the air accumulated 
•within the sac of the pleura : — " The patient had 
received a considerable hurt in his side by a fall 
from his horse. When first seen by Dr. Hunter 
(twenty-nine hours after the accident,) he was in 
bed, panting for breath ; his form was that of a 
human skin stuffed. The inflation was great and 
universal, except in his hands and feet, where it 
was very inconsiderable. The skin was every- 
where shining, as it is when much extended by 
any kind of swelling. The air could easily be 
pressed out from any part, but it immediately re- 
turned upon taking off the hand. When struck, 
his body sounded like a wet drum; and when 
pressed, the air could be felt, and its sound dis- 
tinctly heard. The cellular membrane was less 
inflated, and the skin less distended upon his ex- 
tremities, in proportion nearly to the distance of 
the part from his chest. Those parts on the sur- 
face of the body which have a more loose and 
yielding cellular membrane were proportionabiy 
more swelled ; thence his eyelids were so fixed by 
their own bulk that he had not been able to see 
light from a few hours after the accident happen- 



ed. The penis and scrotum were as much dis- 
tended as in the worst anasarca. 

It is impossible to convey a more accurate de- 
scription of the appearance which this disease 
presents in its most aggravated form. Dr. Hun- 
ter's description of the difficulty of breathing pio- 
duced by the air accumulated within the sac of 
the pleura, is equally characteristic : " His breath- 
ing was very laborious, and rather frequent, in 
the following manner : — his inspiration was so 
short as to be almost instantaneous, and ended 
with that catch in the throat which is produced 
by shutting the glottis ; after this he strained to 
expire without any noise ; then suddenly opening 
the glottis, he forced out his breath with a sort of 
inward groan, and in a hurry, and then quickly 
inspired again ; so tliat his endeavour seemed to 
be to keep his lungs always full. Inspiration 
succeeded expiration as fast as possible. From 
the small quantity that was inspired and expired 
at a time, it was plain that he either had not room 
for a greater quantity, or could not bear a greater 
expansion of the chest." (Med. Obs. and Inqui- 
ries, vol. ii.) 

When the surface of the lung is attached by 
adhesions to the costal pleura, the air which 
escapes from the wounded lung cannot accumu- 
late within the chest, but passes directly through 
the corresponding wound of the costal pleura into 
the cellular tissue on the outside of the thorax ; 
in which case there is no pneumo-thorax, and 
the difficulty of breathing is consequently much 
less. 

Emphysema may likewise be produced in this 
way by penetrating wounds of the chest and 
lungs. It has, however, been observed that these 
wounds are not as constantly followed by emphy- 
sema as fracture of the ribs is. The mechanism 
by which the emphysema is produced is the same 
in both cases, the air first escaping through the 
wounded lung into the sac of the pleura, and 
thence through the wound of the costal pleura 
into the subcutaneous cellular tissue. When the 
wound of the integuments is large, and directly 
parallel to its internal orifice, the air has an open 
and unobstructed issue, through which it passes; 
but when the external wound is narrower than its 
internal orifice, or only communicates with it ob- 
liquely, the air which is forced out may then in- 
sinuate itself into the areolae of the cellular tissue, 
and thus produce emphysema. 

Mr. Hewson endeavoured to produce artificial 
emphysema by cutting and wounding the lungs 
of rabbits and dogs in various ways ; but all his 
experiments were unsuccessful : no air was effused 
either into the cavity of the thorax, or into the 
cellular membrane. From these experiments he 
concluded that a puncture or incision of the lungs 
would seldom produce emphysema, on account of 
the effusion of blood from the divided vessels, and 
that the escape of air is more apt to follow a super- 
ficial abrasion or laceration of the part, such as is 
produced by the extremity of a fractured rib; and 
experience has fully confirmed the accuracy of 
these conclusions. (See Henncn's Principles o*" 
Military Surgery, J. Bell on Wounds, and Barou 
Larrey's Memoires de Chir. Militaire.) 

M. Littre has published a case of emphysemu 



12 



EMPHYSEMA. 



produced by the thrust of a small sword, which is 
remarkable on account of the enormous distension 
of the cellular tissue that took place. The emphy- 
sema commenced soon after the accident, and the 
patient died in two days. On examination after 
death, the emphysematous swelling on the chest 
measured eleven inches thick, on the belly nine, 
on the neck six, and four on the other parts of 
the body ; the wound in the lungs was seven or 
eight lines long, one and a half broad, and one 
deep. (Mem. de I'Academie Royale des Sciences, 
for 1713.) 

Ulceration of the lung, pleura pulmonalis, and 
pleura costalis, is the last mode we have enumer- 
ated in which a communication may be formed 
between the interior of the lung and the cellular 
tissue on the trunk. In some cases a direct com- 
munication is thus formed, as when a circum- 
scribed empyema that points externally between 
the ribs, or an abscess primarily formed in the 
parietes of the chest, bursts internally into the 
bronchi, and thus forms a direct communication 
between the air-passages and the abscess on the 
thorax. In such cases the pus is evacuated by 
the bronchi, and its place is supplied with air, 
which may either infiltrate the cellular tissue of 
the trunk, producing general emphysema, or, if 
the walls of the abscess have been rendered im- 
permeable by adhesive inflammation, may be pre- 
vented from escaping further, and thus produce a 
circumjsribed emphysematous tumour, bearing 
the same relation to diffuse emphysema that phleg- 
monous abscess does to common cellular inflam- 
mation. A remarkable case of this kind in which 
several emphysematous tumours were formed in 
succession over the surface of the chest and neck, 
is recorded by Dr. Duncan, in the first volume of 
the Medico-Chirurgical Transactions of Edin- 
burgh. 

This communication may likewise take place 
indirectly, the air first escaping through an ulcer 
on the surface of the lungs into the sac of the 
pleura, producing pneumothorax, and thence, 
through an ulcer of the costal pleura, into the cel- 
lular tissue of the trunk. A remarkable instance 
of this kind is related by Dr. Halliday. The 
patient had felt unwell for some days, and on the 
evening before his admission into hospital was 
seized with rigors and severe headach ; he had 
also a slight cough, which excited some pain about 
the superior part of the sternum. Early the next 
morning he began to complain of great diihculty 
in respiring; at twelve o'clock the breathing had 
become more severe, his face was turgid, and his 
lips quite livid ; there was also at this time an 
unusual fulness of the neck and breast, which, 
when pressed, yielded an evident crackling noise. 
In about half an hour after, this fulness was be- 
come not only more evident, but was diffused all 
over the chest, and down both arms ; he had now 
the greatest difficulty in respiring at all, and before 
one o'clock every part of the surface of his body 
was become emphysematous, except the palms of 
his hands and the soles of his feet. On inspection 
after death, the right lung was found to contain, 
in its upper lobe, a vomica of about three inches 
in circumference, from which it appeared that 
ubout four ounces of pus had very lately escaped 
iiii". the sac of the pleura, through an opening 



which would scarcely admit the head of a probe : 
upon blowing into the trachea it was observed 
that the air passed freely through this opening 
into the sac of the pleura. On searching for the 
opening through which the air had escaped from 
the cavity of the thorax, a small part of the pleura 
costalis, between the sixth and eighth ribs, was 
discovered with the appearance of being more 
inflamed than any other part ; and nearly in the 
centre of this small spot an opening was detected, 
through which the pleura and cellular membrane 
were easily inflated. (Op. cit.) 

5. Emphysema may likewise be produced by 
penetrating wounds of the chest, even though the 
lung and pulmonary pleura remain uninjured. 
The formation of emphysema in such cases may 
be explained as follows. In all wounds of the 
chest where the air is admitted into contact with 
the pulmonary pleura, the lung generally collapses, 
when not prevented from so doing by emphysema 
of its tissue, or by old adhesions : a sort of false 
respiration is then established, air being inspired 
into the chest through the wound at each dilata- 
tion of the thorax, and alternately expired through 
the same orifice at each contraction of the thoracic 
parietes. But when, as not unfrequently happens, 
the wound remains direct and unobstructed during 
inspiration, but becomes oblique or even closed by 
the alteration in the relative position of the integu- 
ments and ribs during expiration, it follows that 
the air having a free ingress into the thorax during 
inspiration, and not having as free an egress 
during expiration, must suffer such a degree of 
pressure from the contraction of the chest as to 
be forced into the subcutaneous tissue, and so 
produce general emphysema. 

The last variety of traumatic emphysema we 
shall notice is that produced by the escape of air 
from the alimentary canal, through a rupture of 
its parietes. It appears from an interesting work, 
published by MM. Chabert and Huzard, entitled, 
" Observations sur les Animaux Domestiques," 
that this accident is not of unfrequent occurrence 
in ruminating animals, in consequence of their 
food fermenting and generating such a quantity of 
gas as ruptures the internal tunic of the intestines, 
insinuates itself into the subserous cellular tissue, 
and thence extends all over the body. Haller 
mentions a case of emphysema produced in this 
way in a female, whose intestines were so over- 
distended by the quantity of gas they contained, 
that they at last gave way and allowed the air to 
escape into the cellular tissue. (Opusc. Pathol. 
Obs. xxxi. torn, iii.) 

In the eleventh volume of the Archives Gene- 
rales de Medecine there is a very interesting case 
of an extensive emphysema produced in this way 
by a violent contusion on the abdomen. 

We have now enumerated the principal varieties 
of traumatic emphysema, and described the me- 
chanism of their formation ; but we have yet to 
consider another form of this disease, in which the 
air is not introduced from without, but is formed 
witliin the cellular tissue of the part, and which, 
as arising from no very evident cause, has received 
the denomination of idiopathic or spontaneous. 

The air or gaseous product which is formed* in 
spontaneous emphysema may be produced eithei 
by putrefactive decomposition or by secretion. 



EMPHYSEMA. 



in 



1. Spontaneous emphysema caused by the ex- 
trication of gas from a putrefactive decomposition. 
The living body is composed of various elements, 
which are only prevented from decomposing and 
entering into new combinations by the powers of 
life, which, by a counteracting influence, prevent 
the chemical affinities of these elements from 
coming into full operation ; but no sooner do 
those powers cease to act, than the body begins to 
decompose under the influence of the chemical 
and physical laws which govern all inert matter. 
One of the most constant phenomena of this 
putrefactive decomposition is the disengagement 
of various gases ; hence it is that dead bodies 
become emphysematous during putrefaction, and 
that the bodies of drowned men are after some days 
buoyed up and float on the surface of the water. 

The extrication of gas from the death and de- 
composition of a part may likewise occur during 
life, as in the case of gangrene. Indeed this is 
by no means a rare occurrence, particularly when 
the gangrene is of the humid species. " I took 
particular notice (says Dr. Hunter) of the em- 
physema in a case of mortification from an internal 
cause, which began upon the ankle, and thence 
marched upwards upon the limb till it came to the 
groin, when the patient died. The cellular mem- 
brane xmder the skin was very sensibly inflated 
every where, to some distance from the mortified 
part, and I could as easily mark the progress of 
the mortification from day to day by the emphyse- 
ma as by the change of colour in the integuments." 
(Medical Observations and Inquiries, vol. ii.) 
Practical writers have remarked that gangrene, 
when accompanied with emphysema, has a re- 
markable disposition to spread. (James on Inflam- 
mation, p. 96.) 

The period at which the putrefactive decompo- 
sition commences after death depends in a great 
measure on external circumstances, such as heat, 
•jioisture, &c.; but it is also materially influenced 
by the condition of the fluids, which in some 
cases have a much greater tendency to putrescency 
than in others ; as is proved by the well-known 
fact that some bodies will remain for several days 
without exhibiting any sign of decomposition, 
while others from the state of the fluids swell up 
and run into putrefaction immediately after death. 
In the typhous fever that raged in the south of 
Ireland during the year 1817, it was found neces- 
sary to bury the bodies of those that died within 
a few hours after death, and to fill up the graves 
with lime. 

The same tendency to putrescence is some- 
times observed during life, in certain morbid con- 
ditions of the economy, which have hence obtain- 
ed the name of putrid or malignant diseases. 
We know, from direct experiment, that the intro- 
duction of certain deleterious substances into the 
blood, such as pus, putrid animal matter, and cer- 
tain poisons from the animal, vegetable, or mine- 
ral kingdom, produces certain alterations in it, by 
which it loses its power of coagulating, and ac- 
quires a tendency to rapid decomposition. Similar 
alterations are likewise produced in the blood by 
the sting or bite of certain animals, especially 
those of the serpent tribe ; and are also observed 
in the spasmodic cholera, the plague, and other 
diseases of a malignant nature, as it is termed ; in 



all which some of the most constant phenomena 
are a sudden prostration of strength, a constant 
tendency to hemorrhage, and a remarkable dispo- 
sition to mortification wherever congestions are 
formed, (Andral's Pathol. Anat.) In such cases 
the vis viix is actually diminished throughout the 
whole system, and the laws which govern all in- 
organic matter begin to exert their influence over 
the body while yet alive, producing, amongst 
other symptoms of decomposition, spontaneous 
emphysema. 

" A full-bodied middle-aged sailor was seized 
with a putrid fever and sore throat ^ he was bled 
at the beginning, but his blood appearing in a 
loose dissolving state, he was bled no more : about 
the seventh or eighth day of his disease, an em- 
physematous swelling appeared in his face, neck, 
and all over his breast, especially on the right 
side ; the swelling was fomented with sharp vine- 
gar and camphorated spirit of wine, and under 
this treatment totally vanished in two or three 
days, and he soon recovered from the fever ; but 
he continued very weak for a long time, and re- 
mained very scorbutic as he was before the fever, 
his gums being very spongy and bleeding on the 
slightest touch. In this case the emphysema was 
generated merely by the putrescence of the hu- 
mours, as is frequently observed in a less degree 
in and about the incipient gangrene of the limbs ; 
and I am persuaded that this more frequently hap- 
pens in putrid malignant fevers than is commonly 
imagined, (^Huxham, Medical Observations and 
Inquiries, vol. iii. p. 3.3.) 

Frank states that the epidemic fever which 
raged at Bobbio, a small town in Italy, in 1789, 
frequently terminated in general emphysema ; 
and that a similar epidemic had previously occur- 
red in Germany in 1772, during which emphy- 
sematous swellings suddenly appeared on the face 
and neck, and sometimes extended all over the 
body, (De Curandis Hominum Morbis, tom. iv. 
Pt. I. Pneumatosis.') 

Neither is this development of gas from the 
decomposition of the fluids peculiar to man. Dr. 
William Hunter has transmitted to us the history 
of an epidemical distemper prevalent among the 
black cattle in the neighbourhood of London, in 
which it was observed. At first, almost all died 
that were taken ill of it ; most of the diseased 
were emphysematous all over their body ; and on 
dissection the emphysema was found to be uni- 
versal upon all the internal parts, as well as under 
the skin, (Op. cit. vol. ii.) Frank likewise alludes 
to an epidemic dysentery among the black cattle, 
during the progress of which the loins and back 
were frequently observed to become emphysema- 
tous. 

The last illustration which we shall adduce is 
one lately exhibited in Paris, at the Hopital Co- 
chin, an account of which was read by M. Bally 
at the Academic Royale de Medecine. A man, 
twenty-five years of age, who had been ill for fif- 
teen days, was admitted into the hospital with 
symptoms of typhous fever ; he also complainecj 
of pain in the left thigh ; and, whilst he was in a 
state of delirium, said he had been bitten on the 
knee by a dog. The limb was most attentively 
examined, but not the slightest trace of such an 
accident could be discovered. The thigh and 



14 



EMPHYSEMA. 



scrotum were much swollen. He died the follow- 
ing daj'. On dissection, eight hours after death, 
the surface of the body was found soiled by blood, 
which had transuded through the integuments; 
and some blood had also been discharged from the 
nose. The whole body was emphysematous, but 
the left inferior extremity was so to a very high 
degree. It was double its natural size, of a brown 
colour, aLd covered with numerous phlyctenae — 
some black, of great extent, and collected in clus- 
ters, from which escaped a reddish serous fluid 
mingled with a quantity of gas ; others white, 
from which nothing but air escaped. When the 
limb was pressed with the hand, crepitation was 
distinctly heard ; the abdomen was much distend- 
ed with gas ; and in the intestines were observed 
those alterations that are so common in cases of 
typhous fever. Bubbles of air filled the vessels 
of the pia mater, and the left vena saphena. The 
lymphatic ganglions of the mesentery were en- 
• larged and contained gas, which took fire from 
the flame of a taper, and produced an explosion ; 
the same phenomenon also followed the exit of 
the air which was contained in the legs, thighs, 
and scrotum. A puncture was made into the 
abdomen, and the gas which escaped also took 
fire and burned for some time, the flame being 
blue at its base, and white at its summit : the 
combustion extended to the puncture which had 
been made with a trochar ; the edges of this aper- 
ture became black, and were consumed, and the 
aperture itself was enlarged to double its original 
size. The gas which was contained in the sub- 
cutaneous cellular tissue was equally inflamma- 
ble, (London Medical and Physical Journal, for 
June, 1831.) 

This case is peculiarly interesting in conse- 
quence of the light it throws on the etiology of 
spontaneous combustion. On referring to the 
article on this subject it will be found that, in all 
those cases of spontaneous combustion of which 
we have an authentic history, the flame was com- 
municated by the contact of a body in a state of 
ignition, and it is reasonable to suppose that the 
combustion was likewise supported by an inflam- 
mable gas generated within the body, as in the 
present instance. 

Some doubt may be entertained whether this 
inflammable gas should be considered as the pro- 
duct of a putrescent decomposition formed by the 
ordinary laws of chemical attraction ; or as a 
morbid secretion, the product of a vital action, and 
regulated by the same vital laws as other secretions. 

On this subject much yet remains to be dis- 
covered, as our present knowledge only amounts 
to this, that collections of air are sometimes found 
in the living body, under circumstances where 
there is no appearance of their having been gene- 
rated by fermentation or putrefaction ; and that 
both in man and other animals, certain tissues 
possess the power of secreting gas, as, for instance, 
the swimming bladder in fish, the mucous mem- 
brane of the stomach and intestines in man, and 
the mucous membrane of the air-passages, which, 
as the accurate experiments of Dr. Edwards clearly 
prove, secretes a variable quantity of carbonic acid 
and azotic gases. The fact of a gaseous secretion 
being formed by certain tissues in the healthy 
state being established, we are authorized by ana- 



logy to conclude that a secretion of gas may, like 
other secretions, take place as a morbid phenome- 
non in parts where no such secretion naturally 
occurs, more especially as we possess several well- 
authenticated cases in which it is impossible to 
account for the presence of the gas in any other 
way. It must, however, be confessed that we are 
completely ignorant of the causes that influence 
the production of gaseous secretions, and of the 
condition of the solids or fluids most favourable to 
their development : if they are preceded or accom- 
panied by any alterations of texture, they are such 
as entirely to escape our notice. The chemical 
composition of these secretions is also a desidera- 
tum. 

Such being the state of our knowledge, we 
shall not enter into the consideration of any of 
the hypotheses which have been formed on this 
subject, but merely notice the fact, generally ad- 
mitted by pathologists, that spontaneous emphy- 
sema is occasionally produced by a secretion of 
gas within the areote of the cellular tissue. 

Dr. Baillie has recorded a very remarkable case 
of this kind, in which the emphysema was so 
extensive as to affect the alimentary canal and the 
mesentery, as well as the whole of the subcuta- 
neous tissue ; yet in which there was no solution 
of continuity through which the air could have 
been introduced, and no appearance of any putre- 
factive decomposition, by which it could have been 
generated. Frank likewise relates several cases 
of spontaneous emphysema, which it is diflScult to 
account for on any other supposition than that of 
their being a product of morbid secretion ; such, 
for instance, is the case of a young lady at Vienna, 
who became generally emphysematous during 
every paroxysm of a tertian fever, the emphj'sema 
disappearing as the paroxysm subsided. Many 
other curious instances of this disease are to be 
found in the chapter on Pneumatosis, in the 8th 
volume of this author's work " De Curandis 
Hominum Morbis." 

The diagnosis of emphysema seldom presents 
any difliculty when the disease affects the subcu- 
taneous tissue, as it then produces an uniform 
swelling, sufficiently characterized by its hghtness 
and elasticity, and by the peculiar crepitating 
sound and feel it yields under the finger, from the 
displacement of the air from one cell into another. 

The prognosis must be regulated more by the 
cause of the emphysema, and the state of the 
respiratory organs, than by the extent of the em 
physematous swelling. The emphysematous dis- 
tension of the integuments is much more formida- 
ble in appearance than in reality, and, when 
unconnected with any lesion of the organs of 
respiration, may be very extensively diffused 
without producing any injurious consequences. 
Aristotle says that it was a common practice in 
his time to inflate the subcutaneous tissue of ani- 
mals in order to make them fatten more readily 
afterwards : this practice is also alluded to by 
Phny ; and Schulze states that the only eflbct it 
produces on horned cattle is to render them duU 
and heavy for two or three days, after which time 
the emphysema gradually disappears, they recover 
their spirits and appetite, and in the course of six 
weeks become quite fat. (Dictionnaire des Sci- 
Art. Emphyseme.) Hallor and 



ences Medicales. 



EMPHYSEMA. 



Soemmering likewise attest the truth of these 
observations, which at least serve to prove that the 
effusion of air into the cellular tissue is not in 
itself productive of much injury, and that the 
sense of suflbcation, and other formidable symp- 
toms which so often accompany the progress of 
this affection, depend more on the diseases with 
which the emphysema is complicated than on the 
emphysema itself. This conclusion is further 
confirmed by the result of those cases of emphy- 
sema that have been observed in the human 
subject, uncomplicated with any lesion of the 
organs of respiration. Sauvages mentions the 
case of a soldier, who was found asleep in a cave 
by some persons, who inflated his body through a 
quill until it scarcely retained a vestige of the 
human form, — all the lines of demarcation 
between the face, throat, and trunk, being com- 
pletely destroyed. In this case, which may be 
regarded as a rare example of general and exten- 
sive emphysema unconnected with any lesion of 
the respiratory organs, the principal symptoms 
observed were pain and stiflhess from the over- 
distension of the integuments, and difficulty of 
breathing from the impeded motion of the thorax, 
and the congestion of the lungs, arising from the 
pressure which the superficial blood-vessels sus- 
tained ; these symptoms disappeared as the air 
was evacuated through several scarifications which 
the patient had given himself with a knife, and 
his recovery was rapid and complete. 

We may, therefore, conclude that the extreme 
difficulty of breathing, which so frequently ac- 
companies traumatic emphysema, and which is in 
almost every instance the immediate cause of 
death in those cases that prove fatal, is in reality 
produced, not by the emphysematous distension 
of the integuments, but by the air effused into the 
sac of the pleura, or into the interlobular tissue 
of the lung. 

Treatment* — The practice in emphysema 
must be regulated in a great measure by the cause 
of the affection, the extent of the emphysematous 
swellings, and the state of the respiration : the 
general indications of cure may, however, be ar- 
ranged under three heads : 1. to arrest the pro- 
gress of the emphysema, by preventing a further 
effusion of air into the cellular tissue ; 2. to re- 
move the air already effused ; and, 3. to relieve 
the disordered state of the respiration. The means 
employed for the fulfilment of the first indication 
must be regulated by the cause of the emphy- 
sema. 

In spontaneous emphysema, the only effectual 
method of arresting the further progress of the 
disease is, to correct the morbid state of the sys- 
tem on which the development of the gas depends, 
and of which it is merely a symptom. As it 
generally occurs during the progress of asthenic 
or typhoid diseases, aromatic and stimulating lini- 
ments should be applied externally, in order to 
promote the action of the capillaries, while the 
proper remedies adapted to the disease are admin- 
istered internally. Should the emphysema spread 
extensively, it may be proper to relieve the disten- 
sion of the swollen parts by puncturing them with 
the pouit of a lancet. 

In traumatic emphysema, arising from wounds 
of the larynx or trachea, the further effusion of 



air into the cellular tissue may be prevented by 
enlarging the external orifice of the wound, so as 
to make a direct passage for the exit of the air 
during expiration ; the same practice should also 
be adopted when the emphysema arises from 
penetrating wounds of the chest, after which the 
wound should be closed with adhesive plaster. 

When the emphysema arises from a fractured 
rib, the further effusion of air into the cellular 
tissue may be prevented by applying a tight roller 
round the chest, or by making a small puncture 
through the integuments over the seat of the frac- 
ture. 

When the breathing is not much oppressed, the 
application of a bandage may be employed with 
safety and advantage. But as (supposing that 
the surface of the lung is not adherent) the air is 
effused from the wounded lung into the sac of the 
pleura, before it escapes into the cellular tissue, it 
is plain that by applying a bandage round the 
chest, in order to prevent the further progress of 
the emphysema, we only confine the air within 
the pleura, where if it continues to accumulate, 
its presence must give rise to all the distressing 
symptoms of pneumothorax, as it not only com- 
presses the wounded lung, but, by its pressure on 
the mediastinum and diaphragm, obstructs the 
dilatation of the other lung also : under such cir- 
cumstances every facility for the enlargement of 
the chest becomes necessary, in order to admit as 
much air as possible into the lung, which still ex- 
ecutes its functions ; but the effect of the bandage 
is to diminish the dilatation of the sound side as 
well as that of the diseased, and, consequently, to 
increase still farther the embarrassment of the re- 
spiration. 

For these reasons, it is much safer, where the 
breathing is at all embarrassed, to let the air escape 
by making several punctures or small incisions 
over the broken rib, than to confine it with a band- 
age, though the latter practice may be employed 
with advantage in those cases where the quantity 
of air effused into the chest is not sufficient to 
produce much dyspnoea or oppression. 

Lastly, in the cases of emphysema arising frota 
over-distension and rupture of the air-cells, and 
the escape of air into the interlobular tissue of the 
lungs, and thence through the mediastinum into 
the common cellular tissue, the only method of 
arresting the further effusion of air is by employ- 
ing such means as are calculated to diminish the 
violence of the respiratory efforts by which the 
air is forced, at each respiration, into the medias- 
tinum. With this view copious venesection should 
be employed, for the double purpose of relieving 
the pulmonary congestion, and of diminishing 
the mass of the circulating fluid ; for, by lessening 
the quantity of blood to be aerated, we also lessen 
the necessity for taking in so large a supply of air 
for its aeration, and in the same proportion dimin- 
ish the efforts made by the muscles of respiration 
to dilate and contract the thorax. Opiates should 
likewise be ernployed with the same intent, to 
diminish, as Lacnnec expresses it, " le besom de 
respirer :" rest and silence should be enjoined, and 
the antiphlogistic regimen strictly enforced. 

We next come to consider the means of remo^- 
ing the air already effused into the cellular tissue. 
In the slighter cases of emphrsema, where th« 



16 



EMPHYSEMA. 



breathing is not much oppressed, and the quan- 
tity of air effused is not very great, the power of 
the absorbents will generally be found sufficient 
for its removal, and it will only be necessary to 
employ friction over the tumid parts with cam- 
phorated liniment, or some other stimulating em- 
brocation, for the purpose of accelerating the pro- 
cess of absorption : but when the quantity of air 
effused into the cellular tissue is so great as to 
produce considerable distension of the integuments, 
it will be advisable to make several punctures, 
with the point of a lancet, through the skin where 
it is most distended, in order to evacuate the air 
contained underneath. These punctures or sca- 
rifications should be made sufficiently deep to 
divide the cellular tissue, in order to make a free 
exit for the air from the deep-seated as well as 
from the superficial cells. If the air should have 
spread extensively over the body, it will be more 
advisable to puncture the skin wherever the parts 
are much inflated, than to press it along under the 
skin to the punctures which may have been made 
in a distant part. This practice should be adopted 
in all cases of extensive emphysema, from what- 
ever cause i* may have arisen ; as it is perfectly 
free from d<inger, and affords immediate relief to 
the suffering arising from over-distension of the 
swollen parts, and likewise obviates the danger of 
the air forcing its way into the cellular tissue of 
the internal organs. 

We have already seen that in the great majo- 
rity of the cases of traumatic emphysema, the or- 
gans of respiration are more or less injured, and 
that it is from the injury which they sustain that 
the most distressing and dangerous symptoms in- 
variably arise. To them, therefore, our principal 
attention should always be directed, as the most 
important object of our treatment. In all cases 
of extensive emphysema the breathing is more or 
less oppressed, in consequence of the diminished 
mobility of the thorax, and the congested state of 
the lungs caused by the increased quantity of 
blood thrown on them from the surface of the 
body. In such cases, therefore, it will be proper 
to relieve the internal congestions by copious 
bloodletting, and to remove the pressure which 
impedes the motion of the thorax, by evacuating 
the air confined under the integuments, as al- 
ready directed. Venesection is also useful in such 
cases, as the most powerful means we possess of 
anticipating or arresting the development of in- 
flammation. 

Should these measures prove insufficient for the 
rehef of the breathing, we may then infer, (espe- 
cially when the sense of oppression and suffoca- 
tion continues progressively increasing, and other 
symptoms indicate the existence of pneumothorax,) 
that air is accumulating within the chest, so as to 
oppress not the wounded lung only, which was 
collapsed and useless from the first, but the dia- 
phragm and mediastinum, and through them the 
opposite lung also. A freer incision should then 
be made through the integuments .over the seal 
of the injury, and if this does not afford sufficient 
vent to the air confined within, the incision should 
be continued through the intercostal muscles, and 
a small puncture cautiously made into the pleura. 
Mr Hewson, who has written an excellent paper 
on this subject, in the third volume of the Medi- 



cal Observations and Inquiries, recommends that 
the operation should be performed, as in cases of 
emphysema, on the fore part of the chest, between 
the fifth and sixth ribs at the right side, as there 
the integuments are thin, and in the case of air 
no depending drain is required ; but if the disease 
is on the left side, he considers it more advisable 
to make the opening between the seventh and 
eighth, or eighth and ninth ribs, in order that we 
may be sure of avoiding the pericardium. The 
perforation of the pleura will be immediately fol- 
lowed by the escape of the condensed air, the 
pressure of which being removed, the mediasti- 
num and diaphragm will regain their natural po- 
sition, and the opposite lung will thus be enabled 
to resume the free and unobstructed discharge of 
its functions ; after which the wound should im- 
mediately be closed with adhesive plaster, in order 
to prevent the alternate ingress and egress of air 
during the dilatations and contractions of the tho- 
rax. Should the symptoms of oppression and suf- 
focation again return, the wound may be opened 
as occasion requires, and the accumulated air suf- 
fered to escape. 

It sometimes happens that the necessity of per- 
forming the operation of paracentesis is apparent 
from the oppressed state of the breathing, and 
other urgent symptoms of pneumothorax, but that 
from the nature of the accident, and the extreme 
distension of the integuments, it is difficult to as- 
certain at which side the operation should be per- 
formed ; — a point in reference to which an error 
may be attended with the most fatal consequences, 
as actually occurred in a case recorded by Dr. 
Halliday. " The operation of paracentesis was 
resolved on in consultation, and an incision was 
accordingly made between the sixth and seventh 
ribs on the left side of the thorax. As soon as 
the opening was made into the cavity of the chest, 
every distressing symptom became more severe, 
and the patient scarcely survived a quarter of an 
hour." On dissection, it was discovered that the 
operation had been performed on the sound side. 
(Op. cit.) 

In order to avoid the possibility of committing 
so fatal a mistake, the existence of pneumothorax, 
and its precise seat, should always be clearly ascer- 
tained by the physical signs of this disease fur- 
nished by auscultation and percussion (see Pneu- 
mothorax) before the operation is undertaken; 
and should the emphysematous state of the inte- 
guments prevent their employment, or obscure the 
indications which they afford, several punctures 
should be made over the chest, and the air pressed 
towards them, until the emphysematous swellings 
are reduced ; after which, the precise extent and 
seat of the pneumothorax may be ascertained with 
that degree of accuracy which the labours of 
Laennec have rendered so characteristic of this 
department of medical science. 

Some writers use the term emphysema in a 
more extended signification than that which has 
been assigned to it in this article, and apply it to 
all preternatural accumulations of air, in whatever 
part of the body they are situated. But, as these 
collections of air have each received distinct 
names, according to the cavities or organs in 
which they are situated, such as pneumothorax, 
tympanitis, physometra, «&c., their description will 



EMPHYSEMA OF THE LUNGS. 



17 



find a more appropriate place in the articles re- 
Epeclivcly allotted to these subjects. Emphysema 
of the lungs alone forms an exception, and will 
therefore be treated of in the next article. 

R. TOWNSEND. 

EMPHYSEMA OF THE LUNGS. — The 
morbid appearances presented by this disease have 
been noticed by Bonetus, Morgagni, Van Swieten, 
Storck, and other anatomists. In this country we 
have a very correct account of an emphysematous 
lung from the pen of Sir John Floyer; and Dr. 
Baillie's work on Morbid Anatomy contains an 
accurate description of the three principal circum- 
stances which characterize this lesion, namely, 
the great size of the lungs, the dilatation of the 
cells, and the vesicles formed by extravasation of 
air under the pleura. The discovery of its fre- 
quent occurrence as a disease, of its etiology, and 
diagnosis, was, however, reserved for the patholo- 
gical researches of M. Laennec. [An excellent 
essay on the subject has been published by M. 
Louis (translated by Dr. T. Stewardson of Phi- 
ladelphia, in Dunglison's Medical Library for 
1S38.) In order to render the following observa- 
tions intelligible, it will be necessary to premise a 
few observations on the anatomical structure of 
the pulmonary parenchyma, as the emphysematous 
condition of this viscus is, in many cases, merely 
an exaggeration of its natural or healthy struc- 
ture. 

If we examine in a good light the surface of a 
sound lung, we can ascertain by the naked eye, 
through the transparent pleura, that its paren- 
chyma is formed by the aggregation of a multitude 
of small vesicles of an irregularly spheroid or 
ovoid figure, full of air, and separated from each 
other by opaque white partitions. These vesicles, 
which on the surface of the lungs have the ap- 
pearance of small transparent points, are not of an 
uniform size ; the largest are equal to the third or 
fourth part of a millet-seed. They are grouped in 
masses or lobules, divided from each other by par- 
titions of closely condensed cellular membrane, 
very thin, yet thicker and more opaque than the 
partitions between the individual cells. These 
partitions traverse the pulmonary substance in all 
directions, and crossing each other under various 
angles, form figures of different shapes, such as 
lozenges, squares, trapeziums, or irregular trian- 
gles, the bounding lines of which are rendered 
still more defined by the black pulmonary matter 
that is deposited along them. (Forbes's Transla- 
tion of Laennec.) 

If we analyze this structure, we find that it is 
composed, 1st, of the minuter ramifications of the 
bronchi, which go on subdividing and diminishing 
in caliber until they terminate each in a cul-de-sac 
or air-cell, as it is commonly termed, of extreme 
delicacy and minuteness, on the parietes of which 
the pulmonary vessels ramify in an extreme state 
of fineness, (Reisseisen, De Structura. Pulmo- 
num ;) and 2dly, of the common cellular mem- 
brane which serves to connect these air-cells 
together, and which likewise forms several mem- 
branous partitions that divide each lobe into a 
number of distinct lobules, and is hence termed 
the interlobular cellular tissue, each lobule being 
as perfectly isolated from those adjoining it by 

Vol. II 3 b* 



this partition, as each lobe is by its investiture of 
pleura. 

Each of these textures is liable to emphysema, 
and hence we have two varieties of this disease in 
the lung: 1. the vesicular or true pulmonary 
emphysema, (as it is somewhat arbitrarily termed 
by Laennec,) formed by the dilatation of the 
minute bronchi and air-cells, or by the rupture of 
their parietes, by which several contiguous cells 
are thrown into one ; 2. the interlobular emphy- 
sema, formed by the infiltration of air into the 
interlobular cellular tissue. The former usually 
occurs as a chronic disease, while the latter as 
generally assumes the character of an acute affec- 
tion. 

I. Pulmonary or Vesicular Emphysema. — 
In pulmonary emphysema, the size of the air-cells 
is much increased and is less uniform. The greater 
number equal or exceed the size of a millet-seed, 
while some attain the magnitude of hemp-seed, 
cherry-stones, or even French beans, (Laennec.) 
We are disposed to think, however, that cavities 
of such a size are rarely formed by the dilatation 
of individual cells, as in more than one hundred 
dissections which we have made of pulmonary 
emphysema, we never except in one instance saw 
the air-cells dilated to the size of a garden-pea ; in 
the great majority of cases the cavities of this size, 
or even of a less diameter, are formed by several 
cells being thrown into one, in consequence of 
their delicate partitions being overstrained and 
ruptured. In some cases, the walls of the cells 
disappear from one entire lobule, leaving only 
some lacerated filaments traversing its cavity from 
one interlobular partition to another, and in some 
instances these partitions are also lacerated, and 
their respective lobules are thus throvi'n into one 
large cavity, which usually reaches the surface of 
the lung, and forms a projection under the pleura. 
In order to see these alterations of structure, it is 
necessary to inflate the lung and dry it previous 
to examination, as without this precaution the 
cells collapse immediately when cut into, and all 
appearance of emphysema is consequently lost. 

"Emphysema may affect both lungs at the 
same time, one only, or a part of one, or both : 
in the latter case, and, indeed, in any case, as 
long as the disease is confined to a simple dilata- 
tion of the cells, or to the rupture of a few of their 
partitions, and does not form vesicles of any con- 
siderable size on the surface of the lung, it may 
be easily overlooked in the dead body ; for this 
reason, the disease, which is really one of the 
most constant morbid appearances in all cases of 
protracted dyspnoea, has been as constantly over- 
looked, and in this way the lungs of asthmatic 
patients have been regarded as healthy when they 
are in reality emphysematous, and cases of dys- 
pnoea set down as nervous or idiopathic, for which 
anatomy has now discovered an organic cause. 

" When the disease exists in a very high de- 
gree, we cannot help being struck with the ap- 
pearance of the parts. The lungs seem as if 
confined within their natural cavity, and when 
exposed, instead of collapsing as usual, they rise 
in some degree, and project beyond the borders 
of the thorax. If we examine them in this state, 
they feel firmer than natural, and it is more thari 
J usually difficult to flatten them. The crepitation 



18 



EMPHYSEMA OF THE LUNGS. 



they yield on pressure, or being cut into, is less, 
and of a kind somewhat diftbrent ; it is more like 
the sound produced by the slow escape of air from 
a pair of bellows, and the air makes its escape 
from the cells much slower than in a healthy state 
of the organ. When we detach the lung, the 
crepitation is found to be still less perceptible, and 
the sensation conveyed by pressing the parts is 
very like that produced by handling a pillow of 
down. On placing an emphysematous lung in a 
vessel of water, it sinks much less than a healthy 
lung, and sometimes it floats on the surface with 
scarcely any obvious immersion. The pulmona- 
ry tissue is drier in a lung affected with emphyse- 
ma than in a healthy one, and it is unusual to 
find even towards the roots of the lungs any trace 
of the common serous or sanguineous infiltrations 
usually found after death." (Forbes's translation 
of Laennec.) In some cases, however, especially 
when the heart is diseased, and the pulmonary 
.circulation much obstructed, the emphysematous 
lung becomes red and congested. 

It seldom happens that emphysema exists to 
the extent so admirably described in the preced- 
ing paragraph, without occasioning the rupture 
of several of the dilated cells, and it is by no 
means uncommon to find one or more large vesi- 
cular cavities formed, each by the re-union of all 
the air-cells of one entire lobule, and bounded by 
its interlobular partitions, which often remain un- 
injured when the texture of the air-cells which 
they enclose is completely destroyed ; in extreme 
cases these interlobular partitions give way like- 
wise, and several lobules are then thrown into one 
large vesicular cavity, resembling more a bladder 
filled with air, or the vesicular lung of a frog, than 
the parenchymatous texture of the human lung. 
These alterations are most frequently observed at 
the margin of the lung or at its base where it re- 
poses on the diaphragm. 

From these observations it results that emjjhy- 
sema of the lung esssentialiy consists in the rare- 
faction of its parenchyma, produced either by the 
dilatation of its cells, or the rupture of their pa- 
rietes. These lesions may be referred to three 
principal causes: 1. hypertrophy; 2. atrophy; 
3. over-distension of the air-cells. 

1. Hypertrophy. — Laennec has remarked that 
in several cases where the lung has been render- 
ed incapable of performing its functions, the other, 
having double duty to perform, acquires an in- 
crease of volume proportionate to its increased ac- 
tivity of function. Thi<: increase of size appears 
to result from an increase in the capacity of the 
capillary bronchi and air-cells, at the same time 
that their parietes are increased in thickness ; in- 
deed, this is rendered very evident by inflating 
and drying the lung, for when after this process 
it is cut into slices, we at once perceive some 
cells much larger than in the natural state, and 
likewise their parietes much thicker than they 
usually are. The state of the air-cells in this 
form of emphysema may be considered as anala- 
gous to the hypertrophy with dilatation of the 
heart and other hollow muscles. 

3. Atrophy of the Lung. — Whenever any 
cause continues for a certain length of time to im- 
pede the free entrance of air into the pulmonary 
cells, those cells diminish in .number, and the pa- 



renchyma of the lung falls into a state of atrophy. 
Accordingly we find this atro[)hy invariably taking 
place in lungs which have been compressed hy 
pleuritic effusions of long standing, or when the 
principal bronchial tube is compressed by external 
tumours. In old age, likewise, the lungs some- 
times undergo so considerable a degree of atrophy 
that the chest is visibly contracted in consequence ; 
and in such persons they arc small, contain very 
little blood, are remarkably light, and their whole 
texture appears rarefied. If we inflate and dry a 
lung in this state, we perceive a remarkable altera- 
tion in the disposition of the ultimate bronchial 
ramifications, and of the air-cells in which they 
terminate ; they no longer form distinct cavities, 
separated from each other by complete septa: at 
first these septa are only reduced to a state of ex- 
treme tenuity, but at a later period some of them 
appear perforated in one or more points, while 
others seem ruptured and irregularly torn. In 
some cases the walls of the cells disappear altoge- 
ther, and we only find in their stead some delicate 
filaments traversing in different directions cavities 
of various sizes. In the parts of the lung where 
these alterations exist, there are no longer to be 
found either bronchial ramifications, or air-cells, 
properly so called, but merely vesicles of greater 
or less diameter, divided into compartments by 
imperfect septa or irregular laminse, bearing a 
perfect resemblance to the lungs of cold-blooded 
animals. (Andral's Pathological Anatomy.) 

Thus we see how lesions the most opposite in 
their characters, hypertrophy and atrophy, may 
alike produce this disease. But in the case of 
hypertrophy there is only dilatation of the cells 
without laceration of their parietes, unless as an 
accidental occurrence ; whereas, in atrophy of the 
lung, large cavities are formed by several cells be- 
ing thrown into one by the extenuation and rup- 
ture of their walls. Hence arises this important 
dilTerence, that in the first case the number of sur- 
faces on which the blood is exposed to the action 
of the air remains the same, while in the second 
the number of these surfaces is considerably di- 
minished. It is easy to see that the respiration 
will not be equally afliected in these two cases, 
and that the dyspnoea must necessarily be more 
considerable in the latter. There is, however, one 
circumstance that occurs in old age (at which pe- 
riod this alteration, as already stated, most gene- 
rally occurs,) which prevents the respiration from 
being as much embarrassed as wc might a priori 
have expected,— namely, the diminution that takes 
place in the quantity of the blood, or (what comes 
to the same thing) the diminution in the rapidity 
of the circulation. For this reason atrophy of 
the lung, when occurring in old age, should rather 
be regarded as a natural phenomenon resulting 
from the fulfilment of a law in the animal econo- 
my which establishes a constant proportion be- 
tween the quantity of blood to be aerated in a 
given time, and the extent of surface on which 
this aeration is to be accomplished. Thus we find 
that the lung has its maximum of density in in- 
fants, and in those animals that have either a very 
rapid circulation or a very large supi>ly of blood 
and that, on the contrary, the density of the lung 
is at its minimum in old persons, and in such ani- 
mals as receive into their lungs, at each round of 



EMPHYSEMA OF THE LUNGS. 



19 



the circulation, only a small proportion of the 
blood contained in their circulating system, (An- 
dral, Op. cit.) 

Besides these, which may be considered as the 
physiological causes of pulmonary emphysema, 
there are others which produce a similar condi- 
tion of the organ in a manner purely mechanical, 
by keeping the air-cells in a state of over-disten- 
sion. Amongst these may be enumerated violent 
efforts of any kind (especially if often renewed) 
which cause the long-continued retention of the 
breath ; repeated attacks of catarrh, bronchitis, 
asthma, or other diseases of the lungs or air-tubes, 
attended with difficulty of breathing, or distress- 
ing paroxysms of coughing. 

The mechanism of the over-distension and rup- 
ture of the air-cells in these cases may be explain- 
ed by the elforts which are constantly made by 
the powerful muscles of inspiration to introduce 
a fresh supply of air into the air-cells, while that 
which they contain is prevented from escaping 
by pellets of viscid mucus, spasmodic stricture of 
the bronchi, or turgescence of the bronchial mem- 
brane, according to the nature of the disease 
which produced the dyspnoea. In this way, the 
air-cells are kept in a state of over-distension 
which the eflbrts that are made to evacuate them 
only tend to confirm and increase ; and provided 
the obstruction is of some continuance, the dilated 
condition of the cells will be rendered permanent, 
or else their parietes will give way, and allow sev- 
eral cells to be thrown into one. 

From this view of the matter, it will readily be 
understood why all diseases accompanied by pro- 
tracted attacks of dyspnoea, or violent and often 
repeated paroxysms of coughing, are so constantly 
followed by emphysema, especially when occur- 
ring in persons advanced in life, in whom, as we 
have already explained, the lungs are peculiarly 
predisposed to this disease by the atrophy which 
their parenchymatous texture naturally undergoes 
at this period of life. But though the over-dis- 
tension and rupture of the air-cells is in general 
a slow process produced by long-repeated efforts 
to overcome an obstrlictiou to the free exit of their 
contents, and is consequently the result, in most 
cases, of some chronic affections of the bronchial 
tubes, such as dry catarrh, asthma, or the congest- 
ed state of the mucous membrane, so frequently 
produced by organic lesions of the heart ; it may 
likewise be produced in a very short space of time, 
when the efforts made by the muscles of respira- 
tion are violent and constantly repeated. We 
have frequently found the lungs emphysematous 
in children dying of hooping-cough ; and in one 
instance, where the hooping-cough had not last- 
ed longer than three weeks, we saw several cells 
dilated to the size of garden-peas, of a globular 
form, and with their parietes evidently hypcrlro- 
phied. 

[The disease is considered by some to be the 
result of bronchitis — the mucous secretion of 
which cannot readily be expectorated, and there- 
fore dilates the vesicles; but this is denied by 
M. Louis, because, in the cases which he observed, 
the emphysema was rarely preceded by bronchi- 
tis, and the bronchial tubes, in the vicinity of the 
dilated vesicles, were found empty, containing 
neither mucus nor false membrane. A recent 



writer, Dr. G. Budd, ascribes it to a want of elas- 
ticity of the lung, or, in other words, to absence 
of its natural tendency to collapse. The power 
ful muscles of inspiration are continually acting 
to dilate the chest, and thence, by virtue of atmos- 
pheric pressure, the air-cells. This agency is not 
counteracted, as it should be, by the natural elas- 
ticity of the lung, and the air-cells, as well as the 
cavity of the chest, are, in consequence, perma- 
nently dilated. 

The question as to its hereditary nature was 
closely and ably investigated by the late Dr. J. 
Jackson, Jun., of Boston, who attained the fol- 
lowing results. First. Of twenty-eight patients, 
affected with pulmonary emphysema, eighteen 
were the offspring of parents, one of whom had 
been attacked with the same aficction, and several 
of whom had died in the course of it. Li some 
cases, the same was true of the brothers and sis- 
ters. Secondly. Of fifty individuals, not affected 
with emphysema, three only were descended of 
parents who laboured under the disease ; whence 
it would follow, that emphysema is frequently an 
hereditary affection. It would appear, too, that 
hereditary influence is much more marked, where 
the emphysema dates from early infancy, than in 
those in whom it commences immediately before, 
or subsequently to the age of twenty.] 

From whatever cause the emphysema proceeds, 
its constant effect is to render the portion of lung 
affected incapable of performing its respiratory 
functions, as is evident from the absence of respi- 
ratory murmur in the part during life, and the 
difficulty with which the air escapes from the 
overstrained or ruptured cells, even after the lung 
has been removed from the body. Moreover, as 
the emphysema is in almost every instance origin- 
ally produced by turgescence of the bronchial 
membrane, or spasm of the circular fibres, so from 
an effect it generally becomes a cause, and main- 
tains the disease by which it was originally ex- 
cited. Accordingly we find that persons labour- 
ing under emphysema of the lung are particularly 
liable to attacks of asthma and bronchitis, and, 
as a consequence of the latter, and of the efforts 
made during respiration, to hypertrophy or dilata- 
tion of the heart. These intercurrent diseases 
usually occur only after long intervals during the 
first years of the disease ; but when the complaint 
is of long standing, and the patient is far advanc- 
ed in life, the paroxysms become more frequent 
and more severe, each succeeding attack increases 
the extent of the organic lesions and rupture of 
the pulmonary tissues, and sometimes interlobular 
emphysema then ensues. 

From these observations it may be concluded 
that pulmonary emphysema in a moderate degree 
is not a disease of great severity, and that the 
principal danger is to be apprehended from the 
repeated attacks of bronchial disease by which the 
emphysematous condition of the lung was origi- 
nally produced, and to which, in its turn, it seems 
to act as a predisposing cause. 

From the pathology of emphysema, its diag- 
nosis and treatment may be easily deduced. The 
dyspnoea, which is its most constant symptom, 
depends in a great measure on the extent of the 
disease, and the age and constitution of the indi- 
vidual. When the emphysema is rapidly foimeil. 



20 



EMPHYSEMA OF THE LUNGS. 



occupies an extensive portion of the lung, and 
occurs in a young plethoric subject, through 
whose lungs a large quantity of blood is constant- 
ly in circulation, the dyspnoea which ensues may 
be so great as to terminate rapidly in asphyxia. 
But when, as is much more frequently the case, 
the emphysema commences slowly and proceeds 
gradually, the disease is in itself seldom attended 
with any immediate danger, although it renders 
the organ obnoxious to serious or even fatal ef- 
fects from contingent pulmonary disease, which in 
a healthy lung might be borne with comparative 
impunity. 

The difficulty of breathing which accompanies 
this disease is constant, but is aggravated by pa- 
roxysms, which are irregular both in the period 
of their return and their duration ; it is likewise 
increased by all causes which usually increase 
dyspnoea from whatever source arising, such as 
the action of digestion, flatulence in the stomach 
or bowels, anxiety, living in elevated situations, 
strong exercise, running, or ascending a height, 
and above all by the supervention of an acute 
catarrh, to which, as already stated, persons af- 
fected with emphysema are peculiarly hable. Be- 
tween the paroxysms there is no fever, and the 
pulse is generally regular. In slight cases the 
complexion and habit of body are little altered ; 
but when the affection is more considerable, the 
skin usually assumes a dull earthy hue, with a 
slight shade of blue interspersed, and the lips be- 
come violet, thick, and swollen ; there is hkewise 
more or less of cough usually present, though it is 
sometimes so slight as to escape the notice of the 
patient : the expectoration generally consists of a 
greyish viscid mucus. These symptoms may, 
however, be considered as appertaining more pro- 
perly to the disease of the bronchi with which the 
emphysema is complicated, than to the emphy- 
sema itself. 

When the emphysema is confined to one lung, 
or is much greater in one than in the other, the 
side most affected is perceptibly larger than the 
other, its intercostal spaces are wider, and it yields 
a clearer sound on percussion. If both sides are 
affected equally, the whole chest yields a very 
distinct sound, and, instead of its natural com- 
pressed shape, exhibits an almost round or globu- 
lar outline, swelling out both before and behind : 
this conformation of the chest is sometimes so re- 
markable as to render the existence of the disease 
evident from simple inspection. (Laennec, Op. 
cit.) 

The pathognomonic signs of this disease are 
furnished by a comparison of the indications fur- 
nished by percussion and auscultation ; for while 
the sound elicited by percussing the chest over the 
part affected is perfectly clear, or even tympanitic, 
the respiratory murmur is extremely indistinct, or 
even completely extinct, and in its place a slight 
sibilous rale only is heard even during the forced 
inspirations that precede the act of coughing. 
These inspirations will be confirmed by the long 
continuance of the disorder, and the existence of 
an habitual dyspnoea, occasionally aggravated by 
asthmatic paroxj'sms. 

When the disease is so far advanced as to form 
large vesicular cavities under the pleura, its pre- 
sence lunv be recognised by a sound heard during 



inspiration or coughing, which is quite pathogno- 
monic, and described by Laennoc under the appro- 
priate name of i/te crepllous rale ivith large bub- 
bles. The sound of this rAle he compares to that 
which would be produced by blowing into half- 
dried cellular membrane. We have repeatedly 
verified the accuracy of this comparison, and have 
uniformly found on dissection that the sound in 
question'was produced cither by an extreme state 
of vesicular emphysema, or by the interlobular 
form of the disease; we have often found these 
alterations on dissection in cases where this pre- 
monitory sound was never discovered. 

There is another stethoscopic sound which 
Laennec describes as belonging exclusively to in- 
terlobular emphysema, but which we have heard 
on more than one occasion, in cases of vesicular 
emphysema, where the ruptured air-cells projected 
above the surface of the lung. We allude to the 
"friclio)i of ascent and descent," as Laennec 
terms it, which is a sensation of sound of one or 
more bodies rubbing against the ribs, and rising 
and falling during the alternate movements of 
inspiration and expiration. The friction of ascent 
takes place during inspiration, the friction ,of de- 
scent accompanies expiration, and is much more 
constantly audible than the other sound. Most 
commonly the friction seems to take place against 
the costal pleura ; at other times it appears to have 
its site against the diaphragm or mediastinum, or 
between the lobes of the lungs. These sounds 
are sometimes accompanied by a crepitation per- 
ceptible to the hand. 

Treatment. — As pulmonary emphysema 
must, in almost every instance, be regarded as an 
accident caused by some prior disease of the lung, 
the first indication should obviously be to remove 
the original disease, as the most effectual means 
of removing its effect, or, at least, of preventing 
its farther extension. This is perhaps as much 
as we can reasonably hope to accomplish in this 
case, as it is difficult to conceive how any method 
of treatment should restore that portion of lung 
which has once become emphysematous to its origi- 
nal healthy condition. M." Laennec, however, is 
of opinion that this affection should not be consi- 
dered as altogether incurable ; and that, if we can 
diminish the intensity of the cause which keeps 
up the habitual distension of the cells, we may in 
the end hope that these will be actually lessened 
in volume. With this view the cause of the em- 
physema should be combated by prompt and ac- 
tive treatment, and the patient should be made to 
abstain from all the ordinary exciting causes of 
dyspnoea, as they not only produce present dis- 
tress, but likewise keep up the over-distension of 
the cells, and consequently increase the extent of 
the emphysema. 

It has already been stated that emphysema in a 
moderate degree is not a disease of great severity, 
and it is from the supervention of attacks of asthma 
or bronchitis that the principal distress and danger 
are to be apprehended. Every precaution should 
therefore be adopted to remove these affections and 
prevent their recurrence. 

To detail the treatment of these diseases Iiere 
would be to repeat what has been stated in other 
parts of this work : we therefore refer the reader 
to the articles of Asthma, Bronchitis, and Ca 



EMPHYSEMA OF THE LUNGS— E M P YE MA. 



21 



TARiiH, for all the information that can be obtained 
on the subject in the present state of our expe- 
rience. 

Lacnnec recommends frictions with oil as useful 
in diminishing the susceptibility to be affected 
with catarrh ; but a more effectual method of 
accomplishing this object is by sponging the chest 
every morning with vinegar and water, and after- 
wards dry-rubbing the part with flannel or a flesh- 
brusb, as recommended in Asthma. In the case 
of pallid cachectic patients, the subcarbonate of 
iron has occasionally seemed to have a similar 
effect, and to lend at the same time to diminish 
the congestion of the mucous membrane, and also 
the spasmodic stricture of the bronchi. It is also 
of importance to attend to the state of the digestive 
organs, as experience has fully proved that irri- 
tation of the bronchial membrane is very often a 
sympathetic affection depending upon irritation of 
the stomach. Whatever, therefore, is improper 
for a dyspeptic patient should be avoided by those 
who labour under emphysema of the lungs. Warm 
clothing in all cases of delicate mucous membranes 
is particularly necessary, and flannel should be 
worn next the skin during the day, the lower ex- 
tremities should be kept especially warm, and other 
necessary precautions adopted to guard against the 
cold of the winter months. We have known 
many persons affected with emphysema of the 
lungs, and that to a very considerable extent, 
whose breathing was quite good during the sum- 
mer months, but who dreaded the approach of 
winter as the never-failing harbinger of their suf- 
ferings. For such cases the only alternative is to 
spend the winter in a more congenial climate. 
Indeed there is, perhaps, no class of complaints in 
which the beneficial effects of change of air and 
climate are more decidedly manifested than in 
those chronic cases of pulmonary emphysema 
complicated with great susceptibility of irritation 
in the mucous membranes of the air-passages. — 
(See Clihiate.) 

II. IxTEiiLOBTJLAR Emphtsema. — This, as its 
name implies, consists in an effusion of air into 
the cellular tissue, which intersects the pulmonary 
parenchyma, and divides each lobe into a number 
of distinct lobules. This form of pulmonary em- 
physema may be easily recognised in the dead 
body, by the transparency of the interlobular par- 
titions, which contrast strongly with the denser 
structure of the intervening portions of parenchyma. 
Instead of the scarcely perceptible thinness which 
they exhibit in the natural state, these partitions, 
in a state of emphysema, are distended to the 
breadth of two or three lines, or even of an inch 
in some cases. They are generally widest at the 
surface of the lung, where the distension of their 
delicate cells bears an apt resemblance to a string 
of glass beads. Sometimes the emphysema is con- 
fined to two or three interlobular partitions, which 
run parallel to each other from the margin of the 
lung; in some cases these parallel bands are inter- 
sected by transverse partitions likewise in a state 
of emphysema, and the lobules intercepted between 
these intersecting partitions are thus completely 
insulated, being surrounded on all sides by trans- 
parent cellular tissue in a state of emphysema. 

When the disease continues to extend, the air 
passes from one interlobular partition to another, 



until it reaches the root of the lung, from whence 
it soon extends to the mediastinum, and thence 
spreads all over the cellular tissue of the trunk. — 
(See the preceding article.) 

It sometimes happens in this form of the disease 
that the air escapes into the cellular tissue which 
connects the pleura to the lung : in this way one 
or more bubbles of air are formed immediately 
under the pleura, and may be pushed along the 
surface of the lung by the finger, — by which cir- 
cumstance they may be distinguished from the 
vesicles that are formed in the true pulmonary 
emphysema, as the latter are prevented from 
being displaced in this way by their interlobular 
partitions. 

The formation of interlobular emphysema is 
explained by M. Laennec as necessarily depending 
on a rupture of some of the air-cells, and the con- 
sequent extravasation of the air contained in them 
into the cellular substance surrounding the lobules. 
It must, however, be admitted that, even in the 
most extensive cases of this disease, no such rup- 
ture has ever been detected, and that the rupture 
of several cells constantly takes place, and yet not 
a particle of air finds its way into the interlobular 
partitions; nay, that these partitions may them- 
selves be lacerated, and yet no interlobular em- 
physema be produced. Farther observations are 
required to elucidate this subject. 

This form of emphysema is as rare as the other 
is common. It is very seldom combined with the 
true pulmonary emphysema ; and in the great 
majority of cases seems to result from some sudden 
and violent effort of the respiratory muscles, as in 
the forcing pains of child-birth, in raising heavy 
weights, in hooping-cough, &c. Notwithstanding 
the greater density of their lungs, children appear 
to be more liable to this disease than adults. 
(Laennec.) 

The only symptom from which the existence 
of this disease can be suspected, is the sudden 
supervention of dyspnoea after any violent effort 
of the lungs. Its stethoscopic signs are the dry 
crepitous rale with large bubbles, and the friction 
of ascent and descent already described. These 
sounds, it will be recollected, are likewise common 
to the vesicular form of emphysema when the 
pleura is projected by several air-cells thrown into 
one ; perhaps the only method of distinguishing 
between these cases is by the sudden supervention 
of the dyspnoea and of the stethoscopic signs in 
the interlobular form of the disease : fortunately, 
however, the diagnosis is not a matter of much 
practical importance, as in the slighter cases (in 
which alone any ambiguity can exist) the air ap- 
pears to be always absorbed, and the interlobular 
partitions gradually return to their natural state. 
When the aerial infiltration extends to the exter- 
nal parts, the difficulty of diagnosis is at once 
removed, and the disease may be treated on the 
principles already stated in the preceding article 
on general emphysema. j^_ TowNSENi). 

EMPYEMA. 'Kix-vrifia, formed of iv and ttvoi. 
literally signifies an internal collection of pus, and 
in this general sense was employed by several 
ancient authors. By subseauent writers its signi- 
fication has been considerably restricted, and nose- 
logists now apply the terra exclusively to thos»- 



2Z 



EMPYEMA 



collections of pus which are contained within the 
sac of the pleura. In practice, however, it is not 
always easy to determine, a priori, the precise 
nature of the fluid collected within the chest, as 
its physical characters are found to vary consider- 
ably, even in those cases that most closely resem- 
ble each other in their origin, progress, and symp- 
toms. In a case of empyema of two months' 
standing, occasioned by the bursting of a tubercu- 
lous abscess of the lung into the pleura, the effu- 
sion, as observed by the writer, presented all the 
characters of genuine pus ; while in another case, 
where the pleuritic effusion vs-as produced by a 
similar cause, and assumed the same chronic 
form, the operation of paracentesis gave issue to a 
fluid as transparent and colourless as water. Other 
varieties, to be presently enumerated, have like- 
wise been observed in the appearance and compo- 
sition of these fluids ; and as there are no peculiar 
symptoms by which we can always discriminate 
their precise nature during the lifetime of the in- 
dividual, the term is now generally used without 
any reference to the puriform character of the 
effusion. 

When effusion into the thorax takes place in 
an individual of a dropsical diathesis, and seems 
to result from an obstruction to the circulation 
and the consequent transudation of the serous 
part of the blood, rather than from any irritation 
of the secreting surface, the disease is denominated 
hydrotho7-a.z. When the effusion is known to 
consist of blood, as in penetrating wounds of the 
chest, where the pulmonary or intercostal vessels 
have been injured, the term hccmothorax is used 
to express it; and the name oi pneumothorax is 
applied when the effusion is of a gaseous nature. 
With these exceptions, all cases of effusion into 
the pleura that are sufficient to compress the lung 
and impede the function of respiration, are com- 
prehended under the generic appellation of em- 
pyema. 

The pleura, like other serous membranes, con- 
stantly exhales a fluid in the form of vapour, by 
which its surface is lubricated and moistened. In 
the natural state, this perspiratory fluid always 
exists in the form of halitus or vapour; but in a 
morbid state, it is sometimes exhaled in much 
larger quantities, and instead of vapour assumes 
the fluid form. Its qualities are then also mate- 
rially altered, so that, instead of a slight moisture 
barely sufficient to facilitate the gliding motion of 
the opposing surfaces on each other, the serous 
sac is filled with certain morbid secretions, of 
which the following are the principal : — 

1. Serum: its composition is sometimes the 
same as that of the blood, and sometimes differs 
fi-om it in containing a greater or less proportion 
of albumen. 

2. The same combined with a certain quantity 
o.f the colouring matter of the blood. 

3. Pure blood. 

4. Pus. 

5. The spontaneously coagulable and organiza- 
Me matter of which false membranes are formed, 
and which, in their turn, are liable to undergo 
>arious morbid alterations : thus they may become 
inflamed and form new false membranes, or exhale 
blood, or secrete pu*:, melanosis, or tubercle ; or 
iBKtly they may be transformed into fibrous, carti- 



laginous, or osseous tissue. (^Andral, Anatomic 
Pathologique.) 

These morbid productions, either singly or va- 
riously combined, form the principal, if not the 
only ingredients in all cases of pleuritic effusion. 

Our knowledge of the pathology of pleuritic 
diseases in general, and of empyema in particular, 
has been considerably advanced of late years by 
the labours of Laennec, Broussais, and Andral, 
whose works, {Traite d' Auscultation Mediate, 
Histoire des Phkgmasies Chroniques, CUnique 
Medicale,) contain the most complete history we 
possess of these diseases, and may indeed be said 
to form a new era in the pathology of this class 
of affections. 

The effusion of empyema, it is now generally 
admitted, is in all cases principally, if not entirely, 
formed by a morbid secretion from the pleura, and 
may in almost every instance be referred to in- 
flammation of that membrane, either in an acute 
or chronic, an evident or latent form ; and even in 
those cases where pus or other matter is intro- 
duced into the pleura from an extrinsic source, as 
from the rupture of a pulmonary or hepatic ab- 
scess, the collection of fluid which constitutes the 
empyema consequent thereon, does not consist so 
much of the matter of the abscess as of the morbid 
secretion from the pleura, which the irritation 
caused by the presence of that matter produces. 

The nature of the exudation in acute pleuritis 
and the successive stages of its organization and 
conversion into false membrane, are detailed in a 
separate article in this work. (See Pleuritis.) 
For our present purpose, it is only necessary to 
consider those morbid secretions of the pleura 
which evince no disposition to become organized 
or absorbed, but continue to accumulate in the 
shut sac of that membrane, where they act as a 
foreign body, and, by their pressure on the import 
ant organs contained within the parietes of the 
chest, present a constant obstacle to the due pei 
formance of their functions. 

In some cases the effusion consists of a cleai, 
transparent, or lemon-coloured serum ; sometimes 
the effused fluid, though it still retains its trans- 
parency, contains several flocculi of albumen, some 
suspended and others precipitated to the bottom. 
More frequently it is rendered quite turbid by the 
quantity of these minute flocculi that are partially 
dissolved and suspended in it, while the pleura, more 
especially the most dependent portion of it, is co- 
vered with an inorganic layer of a white or yel- 
lowish paste formed by these flocculi, which fall 
in the form of the sediment to the bottom of the 
fluid in which they were suspended. In other 
cases, and they are by far the most numerous, 
the effusion is still more turbid, and of a greyish 
brown or yellow colour— in short, it exhibits every 
intermediate variety of appearance until it pre- 
sents all the characters of genuine t)us. 

These different varieties of effusion arc some- 
times mixed up with the contents of abscesses 
formed in the neighbouring parts, as in the lungs 
or hver, and discharged into the pleura. In some 
cases the effusion is coloured bv the admixture of 
a certain quantity of blood, and in some rare in- 
stances the eflusion has been found to consist en- 
tirely of blood. This sanguinolent effusion some- 
times occurs at the very onset of the pleuritic at- 



E M P Y E ?vl A . 



23 



tack, constituting the primitive hemorrhagic pleu- 
nsy of M. Laeiinec, but is more frequently ob- 
served to occur at a more advanced stage of pleu- 
risy, particularly at the time when vessels begin to 
be formed in (he false membranes, or when a 
fresh attack of inflammation supervenes in them. 
Much importance was attached by the old writers 
to the decomposition of these eftusions and their 
tendency to putrescency ; but the best pathologists 
are now agreed that they never acquire an offen- 
sive odour, or exhibit any sign of decomposition 
unless when the parietes which enclose them be- 
come gangrenous, or when a communication has 
been established between the fluid and the exter- 
nal atmosphere. {Andral d.nA Broussuis, Op. cit.) 

The quantity of these effusions is sometimes so 
very great as to compress the lung into the small- 
est possible compass, and exhaust it of its air more 
effectually than could be done after death by 
means of an air-pump ; at the same time the pa- 
jietes of the chest which are in any degree sus- 
ceptilile of motion are distended to the utmost ; 
the ribs are elevated, and their lower margins 
everted, so as to increase their capacity as much 
as possible ; the intercostal spaces are protruded ; 
the diaphragm is forced down into the abdomen, 
and the abdominal viscera are consequently dis- 
placed, especially the liver, which, in cases of ex- 
tensive empyema of the right side, has been known 
to descend into the iliac fossa. {Stoll, Ratio Me- 
dendi.) The medustinum, in like manner, yields 
to the distending force of the effused fluid, com- 
presses the opposite lung, and allows the heart to 
be thrust completely out of its natural situation. 
We shall presently see that this displacement of 
the heart is one of the most constant and least 
fallible symptoms of empyema. Without this 
great enlargement of the affected side, it would be 
physically impossible that one sac of the pleura 
could accommodate such an enormous quantity 
of fluid as has occasionally been found there. 

A patient of Dr. Croker, of Dublin, was lately 
operated on for empyema by Mr. Crampton, when 
the almost incredible quantity of fourteen imperial 
pints of pus was drawn off from the left pleura. 
In Dr. Archer's case of successful paracentesis of 
the thorax, recorded in the second volume of the 
Transactions of the Dublin Association, eleven 
pints of an inodorous fluid were drawn off, and in 
a few weeks after the patient was quite convales- 
cent. Many other instances might be quoted of 
effusions equally great, or even still more exten- 
sive. 

When the effusion is removed, it seldom hap- 
pens that the pleura is exposed to view, as its sur- 
face is almost invariably covered with a coating 
of adventitious matter, which gives the interior of 
the chest much more the appearance of the walls 
of a large abscess than of a cavity lined with se- 
rous membrane. When, as in cases of latent 
pleurisy, the pleura is covered with a layer of the 
inorganic sediment, which is deposited when the 
effusion is wholly puriform, the layer of matter 
may be scraped ofl' with the handle of the scalpel, 
and then the membrane underneath presents an 
opaque blueish appearance, as if caused by the 
maceration to which it had been so long submit- 
ted. A few red dots or strite, as if laid on with a 
pencil, are ftenerally dispersed over its surface ; 



the membrane itself is seldom if ever really 
thickened, its apparent thickening being in al- 
most every instance caused by a coaling of ad- 
ventitious membrane, which had been exuded 
during the earlier stages of inflammation. When 
the chronic pleurisy succeeds to an acute attack, 
this apparent thickening of the pleura is a very 
constant appearance : sometimes the adventitious 
membrane forms a delicate transparent pellicle, 
which appears perfectly incorporated with the 
subjacent membrane, but may, however, be dis- 
sected from it in one or more layers; sometimes 
the pleura is closely studded with minute trans- 
parent or opaque granulations of a flattened form, 
but most frequently the adventitious coating is of 
an opaque whitish colour, and varies in consist- 
ence from curd or soft cheese to fibro-carlilage, to 
which substances it often bears a very strong re- 
semblance ; and as it is generally composed of se- 
veral strata laid one over the other, it sometimes 
forms a dense solid layer many lines or even 
inches in thickness. When a coating of this de- 
scription is developed on the pulmonary pleura, it 
forms such an unyielding envelope round the lung 
in its compressed, contracted state, as must eftect- 
ually prevent its expansion when the ])ressure of 
the fluid is removed ; and as the lung in this con- 
dition cannot dilate itself promptly enough to 
keep pace with the progress of absorption, when 
the disease terminates favourably, the parietes of 
the chest must necessarily fall in to occupy the 
space left by the removal of the fluid : in this way 
is produced the contraction of the chest which so 
constantly follows the removal of a chronic effu- 
sion from the pleura either by absorption or eva- 
cuation. 

The adventitious membranes which line the 
pleura are liable to a variety of morbid altera- 
tions ; they are evidently susceptible of inflam- 
mation, and likewise of ulceration ; for in many 
cases they have been observed eroded, as it were, 
with small circular pits, sometimes shallow and 
sometimes penetrating through the whole thick- 
ness of the false membrane : occasionally these 
penetrating pits communicate with each other by 
sinuses, or by a more extensive separation of the 
false membrane from the subjacent pleura, but at 
other times the ulceration penetrates through the 
pleura itself. When this happens on the costal 
pleura, it sometimes gives rise to the formation of 
external tumours, which either burst externally 
and discharge the matter of the empyema, or else 
form one or more sinuous passages by which the 
pus is infiltrated into the subcutaneous and inter- 
muscular cellular tissue ; but when it takes place 
in the pulmonary pleura, a communication is 
eventually formed with a bronchial tube, through 
which (according to the jiositicm of the body at 
the time) part of the fluid escapes, or air enters. 
Several cases illustrative of these morbid appear- 
ances are recorded in Dr. Duncan's interesting 
essay on empyema and pneumothorax, in the 
28th volume of the Edinburgh Mciiical Journal. 
The pleura and its adventitious coating of false 
membranes is likewise subject to gangrene, and 
the detachment of the gangrenous eschars some- 
times serves, as in the case of simple erosion jusi 
noticed, to form an outlet by which the niatter cV 
the empyema is evacuated. 



24 



EMPYEMA. 



These false membranes are likewise liable to 
other morbid changes. Sometimes they are trans- 
formed into fibrous or cartilaginous tissue, and in 
some instances they have been found completely 
ossified ; they are also liable to the development 
of various morbid productions, particularly tuber- 
cle. The tubercles that are formed in false mem- 
branes are generally small and very numerous. 
We have, however, once or twice seen tubercles 
as large as filberts in the adventitious coating of 
the pleura; their development is usually a slow 
process, and generally occurs in cases of very 
chronic pleuritis; but sometimes they are gene- 
rated in great numbers with an extraordinary ra- 
pidity. M. Andral has seen the false membranes 
studded with tubercles in persons who died of 
acute pleuritis of only fifteen days' standing. 
(Clinique Medicale, vol. ii.) 

The morbid alterations which we have describ- 
ed may exist in both sacs of the pleura at the 
same time, constituting the double empyema of 
authors, or, as much more commonly happens, 
may occupy one side of the chest ; or, lastly, may 
be limited to a part of one side. When the in- 
flammation is limited to a certain extent of the 
pleura, the effusion is generally circumscribed by 
adhesions which prevent its creeping into the ge- 
neral sac of the pleura ; these circumscribed em- 
pyemas, as they are termed, may exist between 
the lower lobe of the lung and the diaphragm, or 
between two contiguous lobes, between the inner 
surface of the lung and the mediastinum, or be- 
tween any part of its outer surface and the costal 
pleura. Not unfrequently there exist between 
the pleura costalis and pulmonalis a number of 
dense firm adhesions, which, like so many shelves 
or partitions, intersect the effusion, and divide the 
sac of the pleura into a number of distinct com- 
partments. We examined the body of a patient 
who died of empyema in the Whitworth Hospital, 
in March 1830, in whom the effusion was divided 
oy these partitions into three compartments, so 
perfectly distinct from each other, that had the 
operation of paracentesis been performed during 
life, that compartment only could have been eva- 
cuated into which the incision had been made ; so 
that in order to draw off the entire effusion, it 
would have been necessary to perform three seve- 
ral operations. 

The effect of the effusion in compressing the 
lung and diminishing its volume, has already 
been alluded to. When the effusion is very ex- 
tensive, the lung becomes flattened and complete- 
ly flaccid, and its surface corrugated like the 
shrivelled rind of a withered apple ; in this state 
the pulmonary tissue is soft, pliant and dense, 
like a piece of skin, without any crepitation, more 
pale than natural, and entirely without blood ; its 
blood-vessels are flattened and ficquently appear 
quite empty. (^Laennec, Op. cit.) The lung thus 
circumstanced is incapable of expanding for the 
admission of air so long as the fluid continues to 
press on iis surface ; its alveolar texture, how- 
ever, continues very distinct ; and, when its sur- 
face is not coated with an unyielding false mem- 
brane, it may be readily restored to its full dimen- 
e.ions by inflation. The usual position which the 
lung thus compressed occupies, is by the side of 
me spinal column, against which it sometimes 



lies so close as to have escaped the observation of 
several distinguished anatomists who ^cco J Sy 
described it a^s totally destroyed by -}m-^^^' 
Its position may, however, be matenalb alte ed 
by adhesions attaching it to different points of the 
thoracic parietes,and preventing its receding from 
them. We have known the lung retained m 
close contact with the whole anterior part of the 
chest, while the fluid was accumulated in the pos- 
terior part. Andral records a case of empyema, 
in which the upper and middle lobe of the right 
lung were retained in theur natural position by 
adhesions, and formed a complete roof over the 
effusion, which filled the whole of the lower part 
of the chest. (Clinique Medicale, vol. n.) Drs. 
Graves and Stokes relate two remarkable cases of 
empyema in the fifth volume of the Dublin Hos- 
pital Reports, in both of which the lungs were at- 
tached from their apex to their basis by a vertical 
adhesion of about two inches in breadth. Other 
observations might be adduced illustrative of the 
effects of adhesions in preventing the lungs reced- 
ing from the parietes of the thorax ; but for our 
present purpose it is sufficient to remark that, as 
there is no part of the pulmonary pleura which 
may not contract adhesions with the coiTespond- 
ing surface of the costal pleura, so there is no 
part of the chest with which the lung may not be 
retained in contact, even in cases of very copious 
effusion. The knowledge of this anatomical fact 
is, as we shall presently see, of considerable im- 
portance in some cases for determining the pre- 
sence of empyema, and likewise for selecting the 
site of the operation of paracentesis. 

The lung, when compressed in the manner we 
have described in the preceding paragraph, is sel- 
dom attacked with inflammation ; indeed its 
exsanguineous condition vcould seem to guarantee 
it sufficiently from attacks of that nature; but 
there is another morbid alteration which the lung 
under such circumstances frequently presents, 
namely, the development of tubercles. M. Brous- 
sais supposes that their formation is in most cases 
consequent to the effusion, and in a great degree, 
if not altogether, produced by the obstruction of 
the lympathic circulation in the part. (Op. cit. 
vol. i. p. 343.) A more general opinion however 
is, that tubercles are in this, as in other cases, the 
result of a general diathesis, and had probably 
existed in the lung before the effusion had taken 
place. M. Broussais's opinion, if correct, would 
furnish a strong argument in favour of operating 
at an early period of the effusion, in order to anti- 
cipate, if possible, the formation of the tubercles. 
Another morbid appearance which the lung occa- 
sionally presents is the formation of a gangrenous 
or phlegmonous abscess, by which, when the 
pleura is perforated, the effused fluid finds a 
passage into the bronchi, and is expectorated. 

Such are the principal morbid appearances that 
have been observed after death in cases of empy- 
ema: it now remains for us to investigate the 
causes of these anatomical lesions, and to consider 
the symptoms to which they give rise, and by 
which they may be distinguished during life. We 
shall thus be prepared to form a correct estimate 
of the progress and termination of this disease, and 
of the remedies best calculated to arrest its pro 
gress and remove its effects. 



EMPYEMA. 



25 



We have already seen that the matter of empye- 
ma is in most cases formed exclusively by a morbid 
secretion from the pleura, and that, even in those 
instances where pus or other matter is introduced 
into the pleura from the rupture of an adjacent 
abscess, the empyema which follows is principally 
formed by exhalation from the inflamed pleura. It 
may, therefore, be assumed that inflammation of 
the pleura is the proximate cause of empyema. 
As, however, the ordinary course of pleuritic in- 
flammation is not to terminate in empyema, but in 
the exudation of a compound fluid, the serous 
portion of which is subsequently absorbed, and the 
solid part organized and converted into false mem- 
brane, it becomes a question to determine what are 
the circumstances that cause the inflamed pleura 
to secrete the inorganic matter of empyema rather 
than the ordinary organizable product of pleurisy, 
or, in other words, what are the species of pleuritic 
inflammation which have the greatest tendency to 
terminate in empyema. 

These may be divided into four classes : 

1. Acute pleuritis of intense violence. 

2. Acute pleuritis degenerating into the chronic 
form. 

3. Inflammation of the pleura of so low a type 
as not to present the ordinary symptoms of acute 
pleurisy. 

4. Pleuritis caused by the introduction of foreign 
substances. 

1. Acute pleuritis of intense violence. — It very 
rarely happens that inflammation of the pleura is 
so intensely violent as to induce gangrene. When 
it does occur, a copious effusion always follows. 
More frequently, when the pain and other inflam- 
matory symptoms present an unusual degree of 
violence, blood is effused from the inflamed sur- 
face ; generally speaking, the effusion of fluid is 
more abundant in the hemorrhagic than in the 
simple pleurisy, and the tendency to absorption is 
much less. (Laermec, Op. cit. Dr. Forbes's Trans- 
lation.) Lastly, when the pleuritis assumes this 
violent intractable character, a copious secretion of 
puriform matter may take place at an early stage 
of the disease. In a young woman who died in 
the Hardwicke Fever Hospital in the year 1826, 
after experiencing for twelve days before her death 
the symptoms of most A-iolent inflammation of the 
pleura, we found, on dissection, nine jiints of thick 
inodorous pus in the right pleural sac. M. Andral 
records another case in which a purulent eftusion 
was formed with equal rapidity. Although the 
inflammatory symptoms were combated from the 
very outset of the disease by the most active treat- 
ment, on the fifth day the whole of the right side 
sounded dull on percussion, and respiration had 
ceased to be audible there; on the seventh, the 
side was evidently dilated ; and on the eleventh, 
when the disease terminated fatally, the right side 
was found, on dissection, so filled with pus that 
the lung was completely condensed and flattened 
agamst the s[)ine. (Clinique Medicale, vol. ii. case 
13.) Piso likewise relates several cases of acute 
pleuritis, in which the patients died on the fifteenth, 
and some even so early as the ninth day, loith 
their sides full of pus. (De Affect, a Seros. Col- 
luv. ortis, sect. iii. cap. ix.) In those acute cases 
of empyema, the diagnosis is never difficult ; the 
extreme violence of the symptoms, the acute pain 

Vol. II. — 4 ♦ c 



of the side rendered ailmost insupportable by 
coughing, the excessive dyspnoea, general anxiety, 
and high fever, at once point out the highly in- 
flamed state of the pleura, and awaken our atten- 
tion to the possibility of its terminating by effusion : 
when under such circumstances the physical signs 
of effusion (to be presently described) rapidly 
supervene, the existence of empyema is placed 
beyond a doubt. This acute form of empyema 
is, however, much more rare than those chronic 
forms of the disease we are next to consider. 

2. Acute Pleuritis degenerating into the chro- 
nic form. — In the greater number of pleurisies 
which terminate favourably, the process of the 
absorption and organization of the eflfusion is 
completed within a limited period, which, at an 
average calculation, may be estimated at three 
weeks or thereabout. (^Broussais, Op. cit.) When- 
ever the symptoms of pleuritic inflammation out- 
last this period, or when, after a temporary abate- 
ment of the inflammatory symptorgs, the patient 
is seized with rigors and irregular febrile parox- 
ysms similar to those of remittent fever, there is 
reason to fear that the disease is about to assume 
the chronic form, and empyema may be appre- 
hended. In many cases the passage of the disease 
from the acute into the chronic form may be 
traced to the circumstance of its having been 
neglected during its earlier stages, or not combated 
by sufficiently active treatment, or else to some 
indiscretion on the part of the patient during con- 
valescence, particularly in the article of diet ; but 
we likewise meet occasionally with cases of acute 
pleurisy, which, however actively and judiciously 
treated, inevitably degenerate into the chronic 
form. M. Broussais, whose opportunities of ob- 
servation in this matter have been most extensive, 
states, as the result of his experience, that acute 
pleurisy passing into the chronic form is decidedly 
the most frequent cause of empyema. Whenever, 
therefore, the symptoms of pleuritic inflammation 
outlast their ordinary period, and are succeeded by 
those of effusion, we have the strongest evidence 
of the existence of empyema, inasmuch as the 
symptoms of empyema made their appearance 
under those circumstances which most frequently 
lead to such a termination. 

3. Inflammation of the Pleura of so low a 
type as not to present the ordinary symptoms of 
Acute Pleurisy. — Several physicians of the last 
century, and particularly Stoll, had remarked that, 
in many cases of pleurisy, the stitch which com- 
monly attracts attention to the character of the 
disease, is altogether wanting, and that the insidi- 
ous mildness of the whole symptoms in the early 
stage is such as not even to excite any suspicion 
of a severe affection. This latent form of pleurisy' 
is essentially chronic in its progress. At no period 
of its course does it present the intense fevei, 
severe pain, or energetic re-action, which charac 
terize an acute disense. It seldom occurs in per- 
sons of good constitution, but usually attacks 
those who have become cachectic from some cause 
or other, especially persons of a strumous habit 
(^Luennec, op. cit. Dr. Forbes's translation.) 
'I'here are, however, certain exciting causes, which 
are said to have a peculiar tendency to generate 
this latent form of pleurisy, amongst wnich may 
be enunierated contusions of the chest, wounds of 



26 



EMPYEMA. 



the pleura, the cold stage of ague, and metastasis 
of rheumatism. These causes, saj-s M. Broussais, 
(op. cit.) most commonly give rise to pleurisies 
that are latent in their orisrin and chronic in their 
progress. Effusion of puriform matter may like- 
wise take place into the pleura from other causes, 
and without being preceded by the ordinary 
symptoms of pleuritic inflammation. A case of 
latent empyema, consequent on venous inflamma- 
tion, lately occurred in the Meath Hospital, under 
the care of Mr. Porter. The patient, a stout 
young man, in the course of a few days, alter 
having been bled, was seized with symptoms of 
phlebitis, and diffuse inflammation of the cellular 
membrane extending along the arm to tbe axilla. 
The disease proved fatal, and on dissection, in 
addition to the morbid appearances of the diseased 
limb, the pleura of the same side was found to 
contain several quarts of pus. In this case, no 
symptom whatever was observed during life to 
excite any suspicion of the pleura being the seat 
of disease. We have also known the amputation 
for white swelling followed in two instances by 
copious depositions of pus in the pleura, and in 
neither case was there any symptom to indicate 
disease of that membrane. Several similar cases 
have appeared lately in the French journals of 
severe operations, especially those for the removal 
of suppurating parts, being followed by extensive 
depositions of pus in the interior, and on the sur- 
face of different organs.* In these and similar 
cases, it is probable that the depositions of pus are 
formed independently of any inflammatory process 
in the tissue where they are collected, or, to use 
the expression of M. Andral, " that the pus is 
first taken into the circulation, and subsequently 
separated from the circulating fluid, just as mer- 
cury, when injected into a vein, is found to deposit 
its globules in diflerent parts of the body." (An- 
dral's Pathological Anatomy, vol. i. p. 503.) 

Whatever the cause of the latent character of 
the disease may be, experience has fully proved 
that in a considerable proportion of the deaths 
from empyema, no symptom of pleuritic disease 
has been observed until the effusion was fully 
formed ; for which reason the diagnosis of this 
form of empyema is often very obscure. 

4. Pleurifis caused by the introduciion of for- 
eign substances. — Foreign bodies may be intro- 
duced into the pleura either through the lung or 
through the parietes of the chest. Amongst the 
former may be enumerated the contents of tuber- 
culous, pneumonic, or gangrenous abscesses, or 
of pulmonary apoplexy bursting through the pleu- 
ra. Of these the rupture of a tuberculous abscess 
is beyond all comparison the most frequent in its 
occurrence. Within the last four years no fewer 
than eighteen cases of empyema, with pneumo- 
thorax from this source, have come under our own 
observation, fifteen of which were verified on dis- 
section, and we have heard of several other cases 
occurring in the hospitals of Dublin. The rup- 
ture of a pneumonic abscess was supposed, by the 
older anatomists, to be the most prolific source of 
empyema ; but the researches of modern patholo- 
gists have ascertained that the formation of a 

* Soo Recherclies sur certaines Alterations qui se d6- 
veloppent a la suite des lilcssuits ou des operations, par 
M. Mar^chal, in 4to. 1*'28. 



pneumonic abscess is in itself an exceedingly rare 
occurrence, and its bursting into the pleura an 
event still more rare. The rupture of a gangre- 
nous abscess, though of somewhat more frequent 
occurrence, must nevertheless be considered as an 
extremely rare cause of empyema. M. Laennec 
records a case of pleurisy and pneumothorax con- 
sequent to the discharge of a gangrenous abscess 
of the lungs, (Case 15, Op. cit.) ; and he alludes 
to another case in which a gangrenous eschar 
made its way into the pleura, determining a pleu- 
risy which lasted fifteen months. (Op. cit. 227.) 
Andral likewise relates a case of pleuritic effusion 
produced by the bursting of a gangrenous ab- 
scess. (Op. cit. vol. ii. p. 433.) More common- 
ly, however, the gangrenous affection proves fatal 
before sufficient time has been allowed for the 
formation of empyema. In all these cases, the 
rupture of the lung and its investing membrane 
not only pours into the pleural sac the contents 
of the abscess, but likewise allows the air to enter 
at each inspiration, (see Pneumothorax ;) and 
this elastic fluid, by compressing the lung at the 
same time that it irritates the pleura, produces an 
effusion which seldom terminates in adhesion, as 
the lung is, by the surrounding stratum of air, 
compressed against the spine, and thus prevented 
from coming in contact with the parietes of the 
chest. The bursting of pulmonary apoplexy into 
the pleura has, we believe, only teen known to 
occur in four cases, and in each of these the acci- 
dent was instantaneously fatal. (See Pulmonaht 
AropLExr.) 

Various substances may likewise find their way 
into the pleura through the parietes of the chest, 
and by their presence give rise to empyema. Ab- 
scesses of the liver have been known to burst 
through the diaphragm into the pleura. A case 
of the kind is recorded by Morgagni, (Epist. xxiv. 
No. 4.) and another example of this morbid lesion 
is detailed in the Journal de Medecine. (Tom. iii. 
p. 47.) These may, however, be regarded as very 
rare cases ; for when an hepatic abscess takes this 
direction, the inflammation which precedes its 
progress generally produces an adhesion between 
the lung and diaphragm, which prevents the es- 
cape of the matter into the pleura, and directs it 
into the interior of the lung, from whence it may 
be expectorated through the bronchi: two speci- 
mens, exhibiting this course taken by abscesses 
of the liver, are preserved in the museum of the 
Whitworth Hospital. Abscesses formed in the 
walls of the chest may likewise burst into the 
pleura, though, like those of the liver, they more 
frequently open directly into the lung, or point 
externally, and suppurate on the surface. But in 
order to obviate the risk of their breaking inter- 
nally, the safest plan is to make an early opening 
and let out their contents. The importance of 
this practical rule is well illustrated in an inter- 
esting case related by Dr. Duncan, in the first 
volume of the Medico-Chirurgical Transactions 
of Edinburgh, in which the disease having com- 
menced by the formation of an abscess in the 
parietes of the chest, and no external opening 
having been made, the pus eroded the pleura cos- 
talis, en ered the cavity, excited chronic pleuritis, 
and at last found an exit through the lungs by a 
bronchial tube, establishing a communication be- 



EMPYEMA. 



27 



Iween the aerial passages and the external tumour. 
Other remarkable examples of the danger of al- 
lowing these abscesses to burst internally are re- 
corded by Sabatier, (Medecine Operatoire, torn. ii. 
p. 124,) and by De Haen, in his Ratio Medendi. 
Hemorrhage into the thorax from wounded ves- 
sels is not unfrcquently followed by empyema, 
and extraneous substances introduced through 
penetrating wounds of the chest, such as spiculae 
of bone, bullets, pieces of wadding, clothes, &c., 
by their presence in the pleura give rise to inflam- 
mation, which sometimes terminates in empyema, 
but more frequently in the exudation of organiza- 
ble matter, which forms an investment round the 
foreign substance, and limits its eflects to the spot 
where it is immediately situated.* 

Such are the principal lesions that usually pre- 
cede the formation of empyema. We would here 
observe that a knowledge of the antecedent disease 
and of the symptoms preceding the effusion is 
often as essential towards forming a correct dia- 
gnosis of empyema as a knowledge of those symp- 
toms which denote that the effusion has actually 
taken place, since the distinctive characters of the 
affection are often more strongly marked during 
its earlier stages than at its termination. Thus it 
frequently happens that a patient presents a train 
of symptoms which may be referred either to 
hepatization of the lung or effusion into the pleura ; 
and so closely do the symptoms and physical signs 
of those affections resemble each other, that it is 
frequently impossible to distinguish between them 
so long as we confine our attention to the symp- 
toms actually present ; but if, on referring to the 
preceding history of the case, we find that the 
present symptoms were preceded by those of acute 
pleurisy subsequently degenerating into the chro- 
nic form, the difficulty of diagnosis is at once 
removed : unfortunately, however, the symptoms 
which precede effusion are in some cases as 
obscure as those which attend its actual formation, 
and hence arises the principal difficulty in detect- 
ing the presence of empyema. 

Diagnosis* — The diagnosis of empyema has 
been most materially improved of late years. 
Lacnnec's happy application of the principles of 
mediate auscultation to the diagnosis of thoracic 
diseases has added a new and valuable set of phy- 
sical signs to the symptoms of this disease pre- 
viously known ; and the researches of modern 
pathologists, by reducing those symptoms to their 
precise signification, and assigning to each its just 
value as a distinctive character, have rendered the 
diagnosis of empyema as remarkable for accuracy 
and precision as it formerly was for error and 
obscurity. 

Of the symptoms hitherto enumerated by noso- 
lOgists as characteristic of this disease, such as 
« fixed pain in the chest, breathing laborious, but 
easiest in the erect position, difficult decumbiture 
on the sound side, fluctuating enlargement of the 
side affected, and dry tickling cough," (Good's 
Study of Medicine, vol. ii. p. 264,) almost all are 
common to it with other affections, and even of 
these equivocal symptoms the greater number are 
frequently wanting. Under such circumstances 
it is scarcely to be wondered at if the disease was 

* Sco on tins subject, Heniien's Military Surgery, and 
Baron Larrcy's MOinoires. 



constantly mistaken, or its very existence over- 
looked, of which so many examples are recorded 
in medical literature, that the only difficulty lies in 
the selection. 

From a survey of the recorded cases of empye- 
ma, and from our own observation, it is evident 
that, as empyema may exist without its character- 
istic symptoms, so these symptoms may exist 
without empyema; of which fact, indeed, the 
annals of surgery furnish but too convincing 
proofs in the numerous cases where the operation 
for empyema has been performed, but where no 
empyema existed. A remarkable case of this kind 
is recorded by M. Baffos, in his inaugural disser- 
tation, sur VEmpycme, printed in Paris in 1814. 
A patient in one of the pi'incipal hospitals of that 
city presented a combination of symptojns which 
was supposed to demonstrate so unequivocally the 
presence of empyema that the operation of jiara- 
centesis was performed, but to the surprise of the 
operator no fluid was found ; however, as the 
existence of empyema seemed indisputable, it was 
resolved in consultation to make an incision into 
the pleura of the opposite side ; the second opera- 
tion was attended with no better success than the 
first — not a drop of fluid followed the incision into 
either pleura. Dionis relates a similar occurrence 
in the case of the Duke de Montemart, who was 
operated on for empyema, which he had not ; and 
he mentions another case in which a similar mis- 
take cost the patient his life. (Diet, des Sciences 
Medicales, art. Empyime^ Willis likewise 
notices the occurrence of such mistakes : " Novj 
cnim (says he) in aliquibus thoracis paracentesin 
et frustra et non prorsus innoxie celebratam fuis- 
se." (Opera omnia; de Empyemafe.) 

These examples may serve to show the uncer- 
tainty which formerly prevailed in the diagnosis 
of empyema, and the fatal results which too often 
followed these errors of diagnosis; it is needless 
to make any additional observations to point out 
the great practical importance of the improve- 
ments which have lately been made in this depart- 
ment of medical science, by which we are now 
enabled to detect the existence of this disease in 
every case where its diagnosis is a matter of prac- 
tical utility. 

The following symptoms and physical signs are 
those most characteristic of empyema, and when 
they are all combined, may be considered as quite 
pathognomonic: — Difficult respiration, increased 
by motion or exertion of any kind, and considera- 
bly aggravated by lying on the sound side ; a sense 
of fulness and oppression in the chest, amounting 
in some cases to a sense of suffocation ; enlarge- 
ment of the diseased side ; protrusion of the inter- 
costal spaces, with obscure sense of fluctuation 
and oedema of the integuments ; dulness of sound 
on percussion, and absence of the respiratory 
murmur in the diseased side, which remains per- 
fectly motionless ; puerile respiration in the oppo- 
site lung, accompanied with violent action of the 
respiratory muscles ; displacement of the heart ; 
descent of the diaphragm and consequent protru- 
sion of the abdomen : to these characteristic marks 
may be added harassing short cough, small, rapid 
pulse, flushed checks, and other symptoms of 
hectic fever. 

From this combination of symptoms, especiallv 



28 



EMPYEMA. 



when they have been preceded by those of inflam- 
mation of the pleura, the existence of empyema 
may be certainly inferred. It is, however, to be 
remarked, that several of these symptoms vary con- 
siderably, according to the extent of the eflusion, 
and even in those cases where the quantity of 
effusion is the same, according to the date of its 
formation. Thus, when the effusion is rapidly 
formed, the difficulty of breathing is extreme, the 
accompanying fever intensely violent, and the 
anxiety and dread of suffocation urgent and un- 
ceasing : but as the disease continues, these symp- 
toms often assume more of a chronic character ; 
the dyspnoea gradually diminishes, and is perhaps 
only perceptible after exercise or taking food ; the 
fever likewise disappears, or is only perceptible 
towards evening ; and the patient, encouraged by 
this abatement of the symptoms, complains only 
of weakness, and anticipates the speedy restoration 
of his health and strength. But if the physical 
signs of the disease be had recourse to, it will be 
found that this alleviation of symptoms is alto- 
gether illusory, and that the disease, instead of re- 
ceding, has been steadily advancing. 

As, then, the most characteristic symptoms of 
this disease are liable to considerable modification, 
and as several of them are occasionally wanting 
altogether, it may be wortli while to ex^imine each 
symptom separately, to consider how it is produced, 
what it signifies, and what is the precise relation 
it bears to the disease. We shall thus under- 
stand the just value of each, and see how far the 
existence of empyema is proved in the affirmative 
by its presence, or in the negative by its absence ; 
for, as it is impossible to describe every variety of 
combination which the symptoms of empyema 
may present, the only alternative is to enable the 
physician, by acquainting him with the precise 
import of each symptom individually, to form his 
opinion of their signification collectively in what- 
ever form of combination they may present them- 
selves. 

1. Dyspncca. — The difficulty of breathing ex- 
perienced in this disease is generally proportionate 
to the degree of pressure which the lung sustains, 
or, in other words, to the quantity of the effusion. 
To this general rule there are, however, numerous 
exceptions ; indeed tliere is scarcely an author 
who has treated of this disease that does not re- 
count instances of patients labouring under such 
extensive effusion as to compress the greater por- 
tion of one or even of both lungs, whose respira- 
tion was nevertheless not in the least affected. 
(See, for example, Frank, de Curand. Horn. Morb. 
t. viii. p. 232; Duncan, Edin. Journ. loc. cit. ; 
Andral, Op. cit. p. 240.) We must, however, 
suppose that the aeration of the blood is as per- 
fectly accomplished in those cases as when both 
lungs are in the free exercise of their functions, 
for experience has shown that sooner or later 
these patients lose their flesh and strength, and 
their lives eventually fall a sacrifice to the disease. 
Experience has shown that the difficulty of breath- 
ing is extremely urgent when the empyema is 
formed rapidly, but that in more chronic cases the 
dyspnoea is generally proportionate to the violence 
of the fever, and the quantity of the eflusion. Some 
individuals, however, have their breathing much 
more easily affected than others, and accordingly. 



under apparently similar circumstances, the dysp- 
noea continues extremely urgent in some from the 
commencement of the disease to its termination ; 
in others, the respiration is at first greatly affected, 
but the dyspnoea gradually diminishes, and recurs 
only at intervals when the circulation is excited ; 
whilst in a third set, the respiration continues ap- 
parently unimpeded from the beginning to the 
end of the disease. {Andral, Op. cit.) For these 
reasons, and as, moreover, the symptom of dysp- 
noea is common to almost every aflection of the 
lungs, it can only be used in the diagnosis of 
empyema as corroborative of other less equivocal 
symptoms. 

2. Decumlency. — The difficulty which patients 
affected with empyema experience from lying on 
the sound side has been noticed by all writers on 
the subject since the time of Hippocrates. The 
cause of this symptom, which by many is con- 
sidered as quite pathognomonic, has been differ- 
ently explained by authors. Le Dran ascribes 
the sense of suffocation, produced by turning on 
the side opposite to that in which the collection 
of pus is situated, to the mediastinum being on a 
sudden loaded with an unusual weight of fluid. 
(Observations on Surgery, p. iii., edit. 2.) 

M. Richerand, on the other hand, made several 
experiments, by producing artificial hydrothorax, 
to prove that fluid contained in one side of the 
chest, could not, by its gravitation, displace the 
mediastinum, or exert any pressure on the organs 
contained in the opposite side, and hence argued 
that the difficulty of lying on the sound side arises 
not from the pressure of the incumbent fluids, but 
from the obstruction to the dilatation of the sound 
side, produced by placing it under the weight of the 
body. 

In opposition, however, to this ingenious rea- 
soning, we have direct proof of the influence of 
the weight of the fluid ; for we find that in cases 
of pneumothorax with empyema the patient can 
generally lie on the sound side so long as the 
effusion is principally gaseous ; but as the propor- 
tion of ponderable fluid increases, decumbiture on 
the sound side becomes impossible. In like man- 
ner, in cases of empyema the dyspnoea is in gene- 
ral greatly aggravated by lying on the sound side; 
but when the fluid is evacuated, the patient is im- 
mediately enabled to turn on the sound side, al- 
though the necessity for its free dilatation conti- 
nues as great as before — the disease being still in 
a state of perfect inaction. In the case of pneu- 
mothorax with empyema, related in the fifth vo- 
lume of the Dublin Transactions, in which the 
operation of paracentesis was performed, the pa- 
tient was enabled to lie on the sound side the 
night after the fluid was drawn off, though it was 
ascertained by auscultation that the side was then 
filled with air, and the necessity for the free dila- 
tation of the sound side consequently as great as 
before the operation. 

These observations render it probable that the 
difficulty of lying on the sound side arises from 
the load which is thereby thrown on the medias- 
tinum, as well as from the obstruction which the 
muscles of inspiration experience when the side 
which they have to dilate is placed under the 
weight of the body. To avoid this inconvuiience 
patients labourmg under effusion into the r-hest 



EMPYEMA. 



29 



generally lie on the diseased side, or else on the 
back, with a slight inclination of the body towards 
that side. This latter position is the more general 
of the two, and is so very characteristic as to lead 
in some cases to a suspicion of the disease even 
before any farther examination has been made. 
This position, however, is not so constantly 
observed but that we meet with frequent deviations 
from it. When the fever has completely subsided, 
and the thoracic viscera have become habituated to 
ihe pressure of the effusion, the patient can some- 
times lie indifferently on his back or on either 
side ; and there are even some cases on record 
where the patient lay constantly on the sound side. 
J. r. Iscnflamm relates a remarkable case of this 
kind, in which a patient presenting all the usual 
symptoms of empyema, lay generally on the right 
side, which for this reason was supposed to be the 
seat of the disease. Accordingly the operation 
was performed, but no pus was found. The 
patient died, and on dissection it was discovered 
that the left side was the seat of the empyema. 
(Versuche einer praktischen Abhandlung neber 
die Knochcn. Erlangen, 1782.) Morgagni relates 
a case of this kind on the authority of Valsalva, 
and M. Baffos (Op. cit.) records another instance. 
These, however, may be considered as exceptions 
to a general rule, and probably depend on some 
adhesions which confine the effusion, and prevent 
its gravitating to the most dependent part of the 
chest 

When the empyema is double, the patient can 
seldom lie in the horizontal position, but remains 
constantly seated with liis body inclined forward. 
(^Andral, Op. cit.) 

3. Dilataiion of ihe side. — When we strip a 
patient affected with empyema, and examine his 
chest, we generally perceive a marked dillerence 
in the size and shape of the two sides ; that into 
which the effusion has taken place appears con- 
siderably larger ; and tliis difference, which is most 
evident posteriorly, is rendered still more remarka- 
ble by the altered position of the ribs, which con- 
tinue fixed immovably in the position they naturally 
occupy during full inspiration, and contrast strongly 
with the increased motion of the ribs of the oppo- 
site side. The intercostal spaces are also remarka- 
bly wide, and in some cases, especially in thin 
persons, project beyond the level of the ribs : tliis 
latter sign is of considerable importance, as it serves 
to distmguish empyema from hepatization of the 
lung or enlargement of the Uver. 

The increased size of the diseased side is in 
general very perceptible to the eye when it amounts 
to live or six lines : it seldom exceeds an inch and 
a half; but in Dr. Croker's case, already alluded 
to as having had seven imperial quarts of pus 
drawn off at one time, the difference amounted to 
three inches and a half. The most accurate way 
of ascertaining whether any and how much dilata- 
tion exists, is by measuring both sides with a tape 
carried from a central point in the sternum under 
the mamma to the spinous process of the corre- 
sponding vertebra. The xiphoid cartilage fre- 
quently deviates from the median hne, and is there- 
fore an improper point to measure from : it may 
be also well to observe that the right side of the 
chest is generally some lines larger than the lell, 
Drobablv from the greater development of the 



pectoral muscles of that side. Another cause 
which might lead to erroneous conclusions from the 
measiKemcnt of the thorax is, that in those cases 
of empyema where absorption takes place to -a cer- 
tain extent, the parietes of the chest fall in as the 
effusion is removed : in tliis way the diseased side 
comes to measure less than the other ; and if the 
thorax were measured for the first time under 
those circumstances, the sound side would appear 
comparatively dilated, and might be mistaken for 
the seat of the disease. This error would, how- 
ever, be at once rectified on applying the stetho- 
scope. In deformed persons it is impossible to 
draw any inference from measurement of the 
thorax, and in fat persons, especially in females, 
the results are often very unsatisfactory. To sum 
up — dilatation of the diseased side may be con- 
sidered as one of the most valuable symptoms of 
empyema; but it is frequently wanting even in 
those cases where the effusion amounts to several 
pints ; and as it may proceed from various other 
causes, such as pneumothorax, emphysema, and 
enlargement of the liver, so it cannot be relied on 
as a single symptom, though in combination with 
others it is a most valuable diagnostic mark of the 
disease. It should also be recollected that the 
diameter of the diseased side may be less than that 
of its fellow in consequence of the partial absorp- 
tion of the effusion ; indeed this case is by no 
means uncommon. 

4. (Edema of the side. — CEdema of the integu- 
ments of the diseased side, extending sometimes 
to the arm and side of the face, is an occasional 
but no means a constant symptom of empyema ; it 
sometimes occurs at an early stage of pleurisy, 
accompanied with pain and tenderness in conse- 
quence of the inflammation extending to the 
superjacent parts, and in some instances does not 
make its appearance before the last stages of the 
disease. Purple ecchymosed spots have also been 
observed on the most dependent part of the thorax. 
They are said to occur chiefly when the effusion 
is composed of blood. 

5. Fluctuation. — This can sometimes be felt, 
in very thin subjects, through the intercostal mus- 
cles. In a patient who was recently operated on 
in the Richmond Hospital in Dublin, it was very 
evident. It is one of the least fallible signs of 
empyema, but yet should not be trusted to exclu- 
sively, as abscesses occasionally form in the parietes 
of the chest, which yield a similar sensation to the 
finger. In November, 1830, a subject was placed 
on the table in the dead room of the Whitworth 
Hospital, with considerable enlargement of the 
right side, and distinct fluctuation in the intercos- 
tal spaces. On removing the integuments, we 
discovered that both the enlargement and the fluc- 
tuation were caused by an enormous abscess of 
the liver, which had made its way through the 
diaphragm near its anterior attachment to the ribs, 
and had thence poured its contents into the cellu- 
lar tissue wliich invests the muscles on the side 
of the chest, and thus produced the sense of fluc- 
tuation so distinctly felt between the ribs. A case 
nearly similar is recorded by Morand, who per- 
formed the operation of paracentesis between the 
third and fourth false ribs, in a case which ho 
supposed to be empyema from the a3dema of the 
integuments and deep-seated fluctuation ; but he 



E M P Y E M A . 



found to his surprise that the chest was perfectly 
sound, and that the pus which was situated in 
front of the pleura came from an abscess in the 
Hver. {Richter, Chir. Bihl. t. iv. p. H6.) We 
have Hkcwise heard of an encephaloid tumour, 
projecting between the ribs, having been mistaken 
for a case of empyema pointing externally, and 
opened accordingly. 

These examples are sufficient to show the im- 
portance of carefully examining every symptom 
of the disease, instead of trusting exclusively to 
any one sign, however unequivocal it may appear. 
Fluctuation is much more frequently perceptible 
through the intercostal spaces when the empyema 
is circumscribed, than when the fluid is elfused 
into the general sac of the pleura ; in the former 
case it not unfrequently points externally, and l)y 
its rupture aflbrds an exit to the encysted matter. 
When these fluctuating tumours communicate 
with the bronchi through the substance of the 
lungs, they usually acquire an emphysematous 
feel, as in the remarkable case related by Dr. 
Duncan, in which several tumours of this descrip- 
tion were formed over the surface of the diseased 
side. (Medico-Chirurgical Transactions of Edin- 
burgh, vol. i.) 

6. JEgophony. — The peculiar modification of 
the voice, termed jegophony, scarcely deserves to 
be enumerated among the signs of empyema, as 
it is only heard in those cases of effusion where 
the fluid interposed between the surface of the 
lung And the interior of the chest forms a thin 
layer of only a few lines in thickness. Whenever 
the eff'usion exceeds this quantity, the aegophony 
invariably ceases ; and hence it is seldom audible 
in empyema, where the effusion is generally very 
extensive, and accumulates in the most dependent 
part of the chest, instead of forming a thin layer 
over the surface of the lungs, as in cases of recent 
pleurisy. Whenever, therefore, oegophony con- 
tinues to be heard in cases of chronic effusion 
accompanied with cough, difiiculty of breathing, 
and hectic fever, we may infer with tolerable cer- 
tainty that the empyema constitutes an inconsi- 
derable part of the disease, and that tubercles, or 
some other morbid structure, are formed within 
the chest. 

7. Fluctuation on succtission. — The sound of 
fluid splashing within the chest, similar to that 
produced by agitating a cask partly filled with 
water, may sometimes be heard on applying the 
oar to the chest while the body of the patient is 
gently siiaken. This sound has generally been 
described as the most pathognomonic sign of em- 
pyema, but as it never occurs except when the 
pleura contains air as well as fluid, it should more 
properly be considered as a symptom of the em- 
pyema bi'ing complicated with pneumothorax, and 
consequently as affording a more unfavourable 
prognosis, especially where the pneumothorax 
proceeds, as it most commonly does, from the 
rupture of a tuberculous abscess in the lung. (See 
PvErMOTiionAX.) 

8. Dull sound on percussion. — When we em- 
ploy percussion over the chest of an individual 
labouring under empyema, the difference of sound 
elicited from the healthy and the diseased side is 
very striking, the former being clear and hollow, 



while the latter is as dull as if it were the thigh 
that had been struck. When the effusion is so 
extensive as to occupv the whole side of the chest, 
the sound is perfectly dull all over that side, 
unless in those parts where the lung is retained 
in contact with the chest by old adhesions. When 
the effusion only occupies the lower part ol' the 
chest, the dulness of the sound is confined to that 
region ; and in cases of circumscribed empyema 
the dull sound corresponds exactly to the surface 
of the effusion, if the fluid be in contact with the 
costal pleura ; but when it is confined between 
the lung and mediastinum or diaphragm, or be- 
tween two adjoining lobes of the lung, the sound 
on percussion is seldom appreciably altered, and 
hence the diagnosis of these affections is often 
extremely difficult. 

9. Absence of the respiratory sound. — Over 
the same extent of surface, and for the same 
reason that the sound on percussion is rendered 
dull, the respirator)' murmur is totally extinguish- 
ed. This absence of the natural sound is in general 
very apparent, and is among the most constant of 
all the physical signs of empyema. There are, 
however, some sources of fallacy in the evidence 
furnished by the state of the respiration in this 
disease, which it is important to be acquainted 
with. In some cases where the respiratory mur- 
mur is completely extinct, the air still continues 
to enter the bronchial tubes, though it cannot 
penetrate into the cells, and thus bronchial respi- 
ration may be lieard over the situation which the 
condensed lung occupies ; and if the bronchial 
tubes be obstructed with mucus, the different 
varieties of mucous rattle may likewise be heard 
in the same situation. Another circumstance 
calculated to mislead is, that the puerile respira- 
tion of the sound side is sometimes transmitted 
along the parietes of the diseased side, and may 
thus lead the auscultator into the erroneous sup- 
position that respiration was going on in the dis- 
eased side : this error may in general be avoided 
by observing, that the intensity of the respiratory 
murmur gradually diminishes as the stethoscope 
is removed from the sound side ; and this criterion 
will be still farther confirmed by examining the 
ribs of the diseased side, which will be found in a 
state of inaction, if the respiratory murmur be 
really transmitted from the opposite side. Another 
source of error, still more calculated to convey a 
false impression of the true nature of the disease, 
arises from the lung being retained in contact 
with the parietes of the chest by old adhesions. 
In such cases the effusion cannot insinuate itself 
between the chest and the surface of the lung, so 
as to compress its substance or mask its sounds ; 
and hence the respiration continues to be heard, 
more or less plainly, over an extent of surface 
corresponding to the internal adhesions; most 
commonly the lung is attached at its upper lobe, 
more rarely at its lower, and in some instances 
the attachment extends vertically from the apex 
to the basis. These extensive adhesions consti- 
tute one of the most perplexing obstacles to the 
detection of this disease. Whenever respiration 
IS suspended in one lung, the other, if free from 
disease, invariably takes on a compensatory in- 
crease of action, and the respiration becomes 



EMPYEMA. 



31 



puerile : this phenomenon is therefore of consi- 
derable importance, as it announces the ineffi- 
ciency of the opposite lung. 

10. D/splace/nent of the heart. — The science 
of morbid anatomy furnishes numerous examples 
of the strongest membranes yielding to the appli- 
cation of constant and gradually increased pres- 
sure ; in empyema, and likewise in pneumotho- 
rax, the mediastinum yields to the distending force 
of the accumulated fluid, and allows the heart to 
De displaced by its pressure. When the left side 
is the seat of the effusion, the heart is thrust from 
its natural situation, either down into the epigas- 
trium, where it may be seen and felt pulsating, 
or over to the right of the sternum, where its pul- 
sation is sometimes so strong as to attract the at- 
tention of the patient. When the effusion is in 
the right side, the change in the heart's position 
is not in general so remarkable ; but by careful 
examination with the stethoscope, it will generally 
be found to pulsate considerably to the left of its 
natural situation. In two cases, one of which we 
have already alluded to as having been lately ope- 
rated on for empyema, the apex of the heart was 
distinctly felt striking against the stethoscope be- 
tween the fourth and fifth ribs in the left axilla. 

As, then, displacement of the heart is constantly 
produced by effusion into either sac of the pleura, 
and seldom if ever arises from any other cause, 
it may be considered as the most constant and 
least equivocal of all the signs of effusion, and, 
when joined with other symptoms and physical 
signs of empyema, may be regarded as quite pa- 
thognomonic. 

11. Depression of the diaphragm. — The dia- 
phragm in like manner yields to the pressure of 
the incumbent fluid, and descends into the abdo- 
men, thrusting the abdominal viscera before it. 
When the right side of the diaphragm is depress- 
ed, the liver is protruded beyond the margin of 
the ribs, and has even been felt so low as the iliac 
fossa, (S/o//, Ratio Medendi.) Such cases have 
repeatedly been mistaken for enlargement of the 
liver. Of this a remarkable instance has been 
recorded by Roux, in a memoir r.ppended to the 
third volume of Desault's works, where, in a case 
pronounced by one of the most eminent medical 
men in Paris to be an incurable enlargement of 
the liver, the true nature of the disease was dis- 
covered by Bichat, who performed the operation 
of paracentesis thoracis, and thereby saved the 
patient's life. 

12. Abdominal pressure. — Another test of the 
existence of pleuritic effusion imagined by Bichat, 
and described by Roux in the memoir just quoted, 
is the effect of pressure on that side of the abdo- 
men where the effusion is suspected to exist. 
According to those celebrated anatomists, pressure 
exerted on that side of the abdomen correspond- 
ing to the empyema, thrusts the diaphragm and 
the fluid which rests on it up into the thorax, and 
thus, by increasing the pressure of the effusion 
on the lung, produces an insupportable sense of 
suffocation. In those cases where we have em- 
ployed this test, the result was the very opposite 
of that above stated ; for while no uneasiness was 
produced bv pressing up the diaphragm into that 
side where the effusion exiitcd, any attempt to 
stop the free motion of the diaphragm at the other 



side, where alone respiration was still carrried on, 
was most distressing to the patient. The same 
observation- has likewise been made by M. Cho- 
mel, (Dictionnaire de Medecine, Art. Pleurisie.^ 

13. Cough and Expedorufioyi. — The cough 
in empyema is generally short and single, and 
when there is no accompanying bronchitis, is 
often wanting altogether. If there be any expec- 
toration it is generally catarrhal, unless when a 
communication is established between the bronchi 
and the fluid effused in the pleura ; in which case 
the quantity of matter expectorated is sometimes 
so great as to threaten suffocation. This, however, 
can only occur when a large communication is 
suddenly formed, and opens directly into one of 
the principal bronchi ; but in those cases where 
the rupture is small and communicates only with 
the lesser bronchi, the evacuation of the fluid 
must go on slowly and by small quantities at a 
time. In such cases it is often difficult to deter- 
mine the source of the expectoration : some wri- 
ters describe it as possessing a peculiar fetor which 
is quite characteristic. Laennec compares the 
smell to that of gangrene. (Page 447.) Profes- 
sor Nespoli to the smell of assafoetida, " ma assai 
piu di questa penetrante e acido." (Discorso, &c. 
Firenze, 1825.) Some have compared this odour 
to garlic, some to that of phosphoretted hydrogen, 
and others to other ill smells. (Dr. Forbes's Note 
to Laennec, p. 447.) But as thes^ fetid smells 
have all been observed in the expectoration of 
gangrene, and even of simple bronchitis, too much 
importance should not be attached to this sign ; 
more particularly as in many cases of fistulous 
communication between the pleura and bronchi 
no such fetor has been observed. When, however, 
this appearance of the expectoration is accompa- 
nied with a marked improvement of other symp- 
toms, and with a diminution in the diameter of 
the dilated side, we may conclude that a commu- 
nication with the bronchi has been formed ; and 
this diagnosis will be still farther confirmed if the 
signs of pneumothorax supervene in consequence 
of the atmospheric air entering through the com- 
munication. 

14. Fever. — The febrile symptoms which 
accompany this disease vary considerably, accord- 
ing to the f'onslitution of the individual and the 
progress of the effusion ,• tnus. while acute empye- 
ma is usually accompanied with rapid pulse, burn- 
ing heat of skin, and other symptoms of the 
highest degree of febrile excitement, the more 
chronic forms of the disease often present no other 
symptom of fever than a slight acceleration of the 
pulse towards evening, or after taking food ; and 
the patients sometimes even enjoy a state of 
perfect apyrexia. 

It has been remarked by Broussais, and the 
observation has been confirmed by Andral. ^hat 
the hectic of empyema is never accompanied with 
profuse night-sweats, unless when tubercles are 
developed in the lungs or in the false membranen 
of the pleura. Another peculiarity in the hectic 
of empyema, according to Broussais, is, that the 
pulse generally returns to its natural frequency 
after rest, particularly after a night's rest; whereas, 
in the hectic of phthisis, the pulse seldom or 
never comes down to its natural standard. The 
same author likewise states that in the hectic of 



32 



EMPYEMA, 



empyema there is stiJoni any flushing of the 
cheeks, unless when the difficulty of breathing is 
very great, in which case the face and lips present 
a bluish tint and congested appearance, arising 
no doubt from the deficient aeration of the blood ; 
whereas in phthisis the circumscribed flushing of 
the cheeks contrasts strongly with the marked 
paleness of the rest of the countenance. When- 
ever, therefore, the hectic fever of empyema pre- 
sents the symptoms just described as appertaining 
to the hectic of phthisis, we may conclude that 
the eflusion is probably complicated with tubercles 
in the lungs, or in the false membranes of the 
pleura. 

From these observations it appears, that 
although there is no one symptom or physical 
sign which, taken singly, can be considered as 
pathognomonic ; yet, from the combination of 
these symptoms with the physical signs derived 
from auscultation and percussion, the presence of 
empyema may be inferred almost with certainty. 
It must, however, be admitted that we occasionally 
meet with cases in practice in which it is ex- 
tremely difficult to ascertain the existence of effu- 
sion. This diificulty, in some instances, depends 
on symptoms being present which appear incom- 
patible with the presence of effusion, and in 
others on the only symptoms present being com- 
mon to empyema with other afitjctions, and con- 
sequently insufficient to decide the true nature of 
the disease. 

To the former class belong those cases of em- 
pyema in which the lung is extensively attached 
to the costal pleura, and those of circumscribed 
effusion situated in the interior or bottom of the 
chest ; in both of which cases, contrary to what 
usually occurs in empyema, the respiration con- 
tinues audible, and the sound on percussion is 
little if at all affected. The diagnosis of these 
cases has already been the subject of considera- 
tion. 

The diseases which from the similarity of their 
general symptoms and stethoscopic phenomena 
are most liable to be confounded in practice with 
empyema, are tubercular consumption, hepatiza- 
tion of the lung, the development of morbid 
growths in the pleura, and, when the disease is at 
the right side, enlargement of the liver. 

We shall now offer a few remarks on the dis- 
tinctive characters of these different affections. 

1. Tubercular Consumption. — The general 
symptoms of phthisis and empyema are sometimes 
so precisely similar as to have deceived even the 
most experienced practitioners. The stethoscopic 
phenomena of these diseases are, however, so very 
characteristic, that it is scarcely possible now to 
confound them. In the first stage of phthisis, 
when the tubercles are in their crude state, the 
respiratory murmur is seldom if ever so completely 
suppressed as in empyema. In the former disease 
the absence of respiration first commences, and is 
always most marked, in the upper lobe, and in the 
latter in the lower lobe. At a more advanced 
stage, when the tubercles are softened, the charac- 
teristic signs of pectoriloquy, mucous rale, and 
guggling cough, at once point out the true nature 
of the disease, and prevent the possibility of 
nustaking it for empyema. 

2. Hepatization of the Lung. — Owing to the 



similarity of the stethoscopic phenomena which 
hepatization presents, it is much more likely to be 
confounded with empyema. The following signs 
will, however, seldom fail to enable the physician 
to distinguish these diseases. In hepatization the 
antecedent symptoms are those of the first stage 
of pneumonia, and the cough is usually attended 
with characteristic viscid sputa ; the respiration is 
never totally suppressed, but its place is supplied 
by strong bronchial respiration and resonance of 
the voice ; the side is never enlarged ; the inter- 
costal spaces are never protruded ; and the heart 
is never displaced ; either of these symptoms 
occurring, will, therefore, at once decide in favour 
of empyema. To these distinctive characters we 
may add that chronic empyema is, comparatively 
speaking, a disease of common occurrence; 
whereas chronic hepatization is an affection so 
rare, that Laennec commences his chapter on the 
subject by questioning the reality of its existence. 
This opinion is confirmed by the experience of 
Andral, who states (Op. cit.) that of one hundred 
and twelve cases of pneumonia treated in La 
Charite only one exceeded thirty days, or could 
be regarded in the light of a chronic disease. 
Chomel and Louis likewise concur in describing 
chronic peripneumony as one of the rarest forms 
of pulmonary disease. 

3. Tumours in the sac of the Pleura. — The 
same remark is likewise applicable to the develop 
ment of those tumours in the pleura which com 
press the lung and occupy its place. A remarka- 
ble case of this kind is related by Corvisart in the 
" Bulletins de la Faculte de Medecine." The 
patient's symptoms were such as to lead this 
accurate observer into the belief that the disease 
was empyema; but, on dissection, he was sur- 
prised to find instead of pus a solid substance 
answering to Laennec's description of encbpha- 
loide, occupying the entire of the left side, the 
lung having, as he describes it, totally disappeared. 
An analagous case is recorded by Boerhaave, as 
occurring in the person of the Marquis de St. 
Auban. (^Zimmerman, Traite de I'Experience.) 
M. Kecamier found in the body of a patient whom 
he considered as affected with empyema, one side 
of the chest entirely filled with a mass of tuber- 
culous matter. A still more remarkable example 
of this disease is recorded by Laennec (Op. cit.), 
to whom it was communicated by M. Cazol. 

4. Enlarged Liver. — The last disease which 
we shall enumerate as liable to be confounded 
with empyema is enlargement of the liver. This 
viscus is sometimes so much increased in size as 
to ascend into the thorax, and compress the lung 
into the upper and back part of the chest. In 
such cases the sound on percussion is as com- 
pletely dull, and the respiratory murmur as per- 
fectly extinct, as in empyema. Neither is the diag- 
nosis always facilitated by referring to the earlier 
symptoms of the disease, as empyema is often 
ushered in with the same dull pain in the hypo- 
chondrmm that usually attends hepatic disease; 
and the projection of the liver beyond the margin 
of the ribs may proceed either from enlargement 
ot that organ, or from its being thrust down by 
the pressure of the superincumbent fluid. Such 
are the principal points of similitude between 
these diseases, which have frequently imposed on 



EMPYEMA. 



33 



•lie most experienced practitioners, but which it is 
o( the greatest importance to distinguish, as is ex- 
emplified in the case already quoted from the me- 
moir published by Roux, where the life of the pa- 
tient supposed to be labouring under incurable 
disease of the liver was saved by the operation for 
empyema, which the accurate discernment of Bi- 
chat discovered to be the real disease. It is only 
necessary to allude here to the possibility of mis- 
taking these diseases one for the other, as it sel- 
dom happens that their diagnosis is not rendered 
sufficiently easy by the presence of some equivo- 
cal symptom, either of hepatic disease or of em- 
pyema. 

Prognosis of Empyema. — The prognosis in 
this disease is generally unfavourable, as by far the 
greater number of cases terminate fatally, what- 
ever treatment is adopted. But as empyema is 
more pro [icily the termination of a pre-existing 
disease thun a primary or specific affection, it is 
impossible to form a correct prognosis of its proba- 
ble termination in any given case without taking 
into consideration the character of the pre-existing 
disease and the condition of the lung and pleura, 
as well as the amount of the effusion and the pos- 
sibility of its removal ; for on these circumstances 
the issue of the case principally depends. Thus, 
for example, while the empyema produced by the 
rupture of a tuberculous abscess in the lung has 
never, as we believe, been known to terminate 
otherwise than in death, the empyema which suc- 
ceeds to penetrating wounds of the chest has in a 
great numlier of cases terminated favourably. (See 
Baron Larrey's Me moire sur les effets de I'opera- 
tion de I'empyeme, Chirurgie Militaire.) In the 
former case the efiusion is produced by, and com- 
plicated with an incurable affection of the lung, 
while in the latter it is unconnected with any or- 
ganic disease of the thoracic viscera. 

In acute empyema, when the effusion increases 
rapidly, and is accompanied with great difficulty 
of breathing and febrile excitement, the disease 
may prove fatal by suffocation during the acute 
stage, or, as more frequently happens, may de- 
generate into the chronic form. 

In chronic empyema, whether proceeding from 
acute or chronic pleurisy, the termination of the 
disease, when abandoned to the resources of na- 
ture, is almost invariably fatal; though, if we 
could place implicit confidence in the representa- 
tions of the older writers, it would appear by no 
means uncommon that it should terminate by ab- 
sorption, or even by critical evacuation. Billard 
states that a case of empyema, on which he was 
on the point of operating, terminated favourably 
hy a critical sweat, produced and kept up by the 
internal use of the acetate of ammonia, which he 
therefore recommends as a most efficacious reme- 
dy in this disease. (Dictionnaire des Sciences 
Medicales, Art. Empycme.) The efliision of em- 
pyema has also been stated to have passed off, by 
metastasis, from the intestinal canal, from the 
bladder, from the vagina ; and is said ir* one in- 
stance to have vanished on the eruption of a sca- 
bies. (Good's Study of Medicine, vol. 2.) Dr. 
Darwin relates the following extraordinary in- 
stance of recovery from this disease : — A servant 
man, after a violent peripneumony, was seized 
with symptoms of empyema, and it was determin- 

VoL. II — 5 



ed after some time to perform the operation : this 
was explained to him, and the usual means were 
employed by his friends to encourage him, by 
advising him " not to be afraid," by which good 
advice he conceived so much fear that he ran 
away early next morning, and returned in about 
a week quite well. Without, however, incurring 
the imputation of scepticism, we may perhajjs be 
permitted to doubt the accuracy of these observa- 
tions, and to question whether the disease thus 
marvellously cured had ever existed, especially as 
we have seen how very inadequate the means of 
ascertaining the existence of the disease were in 
those days. 

Of eighteen cases of chronic pleurisy record- 
ed by Broussais in his " Histoire des Phlegma- 
sies Chroniques," only one ultimately recovered. 
Laennec likewise states that the disease has sel- 
dom any natural tendency towards resolution, and 
this statement has been so fully confirmed by the 
experience of modern physicians, that doubts are 
now very generally entertained whether the fluid 
is ever removed by absorption in cases of genuine 
empyema; and, accordingly, it has been recom- 
mended on high authority, that the operation of 
paracentesis should be performed as soon as ever 
the presence of empyema can be ascertained with 
certainty, "In tali casu," says Willis, " phar- 
macia haud multum opus erit, sed tantum corpore 
preparato illico ad lateris apeitionem procedatur. 
(De Empyemate, p. 97.) 

But although the instances of recovery from 
this disease by the absorption of the effusion are 
not sufficiently numerous to inspire us with much 
confidence in the efficacy of the remedies usually 
employed for that purpose, still there are a suffi- 
cient number of well-authenticated facts to prove 
the possibility of the disease terminating in this 
favourable manner, and, consequently, to establish 
the propriety of trying the effect of appropriate 
remedies before having recourse to the operation, 
unless in those cases where the effusion is so ex- 
tensive as to preclude all reasonable prospect of 
its absorption, or the symptoms of suffocation so 
urgent as to require the immediate evacuation of 
the fluid. 

Treatmcntt — In order to promote the resolu- 
tion of this disease, the first object of medical 
treatment should be to moderate any febrile excite- 
ment which may arise, as experience has fully 
proved that a state of perfect apyrexia is the most 
favourable condition for the absorption of the ef- 
fusion ; for this purpose it is seldom necessary to 
have recourse to general blood-letting, unless in 
cases of internal hemorrhage. Cupping over the 
part or leeches may occasionally be applied with 
advantage when an exacerbation of the pain and 
other symptoms indicates the supervention of a 
fresh attack of inflammation on the diseased sur- 
face ; but a rigid enforcement of the antiphlogis- 
tic regimen will be found the most effectual method 
of subduing the fever. " This point is of such 
paramount importance," says M. Broussais, " thai 
I regard it as the basis of the treatment in all 
those chronic affections of the chest which are 
sufficiently violent to excite fever; indeed, tho 
physician cannot be too strongly impressed with 
the idea that, so long as any fever contmues, the 
more his patient eats the shorter time he Uvea 



84 



EMPYEMA. 



and that by lowering his diet he will take a more 
jirompt and effectual method of removing the fe- 
brile paroxysms than by repeated bleedings, or by 
covering his chest with blisters." (Phlcgmasies 
Chroniques, vol. i. p. 355.) These observations 
are particularly applicable to those paroxysms of 
fever which supervene during the course of chronic 
pleurisy: for so long as they continue, any at- 
tempt to repair the strength by the use of nutri- 
tious diet will only aggravate the fever and in- 
crease the consequent debility. When, however, 
the fever subsides, it is of the greatest importance 
to support the patient's strength by the use of 
light nutritious diet, and even by the administra- 
tion of tonics and stimuli when required, taking 
care, however, to avoid pushing the tonic treat- 
ment so far as to reproduce fever. At the same 
time, the absorption of the fluid may be promoted 
by increasing those natural discharges of which 
nature sometimes avails herself, as of so many 
emunctories, for the ev^acuation of internal suppu- 
rations, and by exciting artificial discharges from 
the surface by the use of counter-irritants and de- 
rivatives. 

Purgatives, according to Laennec, to be useful, 
ought to be pretty frequently repeated. They are 
particularly indicated subsequently to blood-let- 
ting, when the abundance of the effusion, or the 
rapidity of its formation, and the general symp- 
toms, give reason to presume that the pleurisy is 
hemorrhagic. 

On the same authority, diuretics are said to 
have no evident effect upon the absorption, unless 
they are given in larger doses than is customary. 
He was in the habit of carrying the acetate of 
potass to the extent of six drachms or even of 
two ounces in the day, and gave nitre in doses of 
from forty grains to three or four drachms if the 
patient bore it well. With this latter Laennec 
sometimes combined sal ammoniac, according to 
the method of Trilier, and also gave with advan- 
tage the extract of squills, as recommended by 
Quarin, in a minimum dose of two grains every 
three hours. (Dr. Forbes's Translation of Laen- 
nec, p. 473.) 

Diaphoretics and expectorants have likewise 
been found serviceable in some instances, and 
may therefore deserve a trial, especially in those 
cases where the efforts of nature manifest any 
tendency to produce a critical evacuation by dia- 
phoresis or expectoration, in which case the pro- 
priety of promoting the discharge established by 
nature is manifestly in(iif:'tcd. 

So long as any fever is present, counter-irritants 
of any kind should be employed with the greatest 
caution ; but when the fchrile symptoms subside, 
a large blister may be applied with advantage 
over the affected side, and kept open for several 
days, provided it does not produce much constitu- 
tional irritation. If the effusion does not dimin- 
ish under this treatment, it will be advisable to 
heal the blistered surface and try the effect of a 
different kind of counter-irritant ; for this purpose 
setons or caustic issues may be used, but, in order 
to produce any decided effect, they should be kept 
discharging fo; a considerable length of time. 
The use of the moxa is strongly recommended by 
]3aron Larrey, who states that he has seen it act 
T^oet beneficiaJlv as a revulsive in several cases of 



empyema. (See Observations sur Ics Effets de 
Moxa, in the Jourrial Complcmentaire, torn, v.) 
The actual cautery is another powerful revulsive, 
which was much employed by the older surgeons, 
who seem to have frequently had recourse to it 
with decided benefit as a means of cstabhslnng a 
counter-irritation and derivation from the diseased 
pleura. 

There is another mode in which the efforts of 
nature occasionally effect a cure in this disease, 
namely, by the formation of a fistulous passage 
through the lungs or through the walls of the 
chest, which serves as an outlet to evacuate the 
matter contained within the pleura. This spon- 
taneous evacuation of the matter of empyema 
occurs chiefly, if not exclusively, in those cases 
where the empyema is circumscribed, and the 
fluid is prevented from escaping laterally by adhe- 
sions. When no such adhesions exist, the fluid, 
having full hberty to accumulate within the chest, 
seldom points extemall}'^ ; and, accordingly, it is 
extremely rare to find any appearance of erosion 
or ulceration in the costal or pulmonary pleura 
when the effusion occupies the general sac of the 
pleura, though such appearances are by no means 
uncommon when the effusion is circumscribed. 

Laennec states that the spontaneous cvacuatioi 
of the matter of empyema is more frequently ef- 
fected by rupture into the bronchi than by ulce- 
ration through the walls of the chest; but in com- 
paring the records of those cases vi'hich have been 
published in this countrj^ as well as in France, it 
appears that their comparative frequency is pretty 
nearly equal. 

When the matter bursts into the bronchi, the 
communication is generally formed by the detach- 
ment of a gangrenous eschar, or by erosion and 
ulceration of the pleura and pulinonary substance. 
The passage thus formed is usually lined with an 
adventitious membrane, which prevents the matter 
from infiltrating the tissue of the lung, and con- 
ducts it directly into the bronchi, from whence it is 
subsequently removed by expectoration. Many 
instances of tliis mode of the escape of pus are 
on record. Dr. Forbes met with a case of this 
kind, and has had several undoubted instances re- 
lated to him by practitioners. (Op. cit.) Brous- 
sais gives two cases of gangrenous perforation of 
the pleura pnlmonalis, and another in which the 
communication seems to have taken place from 
simp'.<j ulceration. Le Dran met with four cases 
in winch the disease terminated in this way. A 
case of rupture of a circumscribed empyema into 
the bronchi, followed by a copious expectoration 
of fetid matter, lately fell under the observation of 
the writer of this article. Laennec also has seen 
the effusion of chronic pleurisy burst into the 
bronchi, and Andral observed a similar occurrence 
in a case of acute empyema. Several other cases 
may likewise be found in the periodical literature 
of this country. 

When tl'.e empyema is about to make its way 
outwards through the parietes of the chest, the 
escape of the matter is usually preceded by the 
appearance of a soft, doughy, inelastic swelling 
of the integuments, which generally advances In 
the course of a few days, so as to form a distinct 
fluctuatmg tumour, and either breaks spontane- 
ously, or else rexjuires an artificial opening to be 



EMPYEMA. 



made through the integuments, in' order to give 
issue to the matter contained underneath. This 
ulcerative process generally commences in the 
costal pleura or in the false membranes with which 
it is Hned, and passes in succession through the 
superincumbent parts; sometimes, however, it 
commences by the formation of an abscess in the 
walls of the chest, which, bursting both externally 
and internally, forms a fistulous passage for the 
escape of the contained fluid. Instances of this 
termination of empyema are to be found in the 
writings of almost every author who has treated 
on tliis subject. Andral gives three cases in 
which the matter made its way through the inter- 
costal spaces, and a fourth in which it perforated 
the diaphragm. Several similar cases are recorded 
in lie Dran's observations, and in other works on 
surgery. 

The escape of the matter either through the 
bronchi or through the walls of the chest is gene- 
rally followed by immediate relief of all the most 
urgent symptoms, and in some cases the fistulous 
passage soon ceases to discharge, and cicatrizes ; 
but in other instances the fistula remains open for 
several months, or even years, and continues to 
discharge a greater or less quantity of matter, 
until the suppurating surface gradually diminishes, 
and becomes at length obliterated by the cohesion 
of the walls of the abscess. Sometimes, however, 
the evacuation of the matter, so far from produc- 
ing any alleviation of the symptoms, seems only 
to aggravate the disease and accelerate its fatal 
termination. (See the seventeenth case in the se- 
cond volume of Andral's Clinique Medicale.) 

In some cases the formation of one outlet is fol- 
lowed by the formation of several others in suc- 
cession, as in a remarkable instance published by 
Dr. Duncan, in the 28th volume of the Edinburgh 
Medical Journal. A still more remarkable case 
of this kind is related by Dr. Betty, in the London 
Medical Repository for March, 1823. 

This successive formation of several outlets for 
the evacuation of the matter of empyema occurs 
chiefly in those cases where the matter is confined 
in distinct compartments, having no communica- 
tion one with the other, and, consequently, requir- 
ing each a separate outlet for the evacuation of 
its contents. A second orifice is also occasionally 
required when the outlet first formed is situated 
in the upper part of the chest ; for in such cases 
that portion of the fluid which stands below the 
bed of the outlet has no means of escaping unless 
by the formation of another passage in a more 
dependent situation. 

Paracentesis. — When, however, as too often 
happens in this disease, there exists no reasonable 
prospect of the eflusion being removed by absorp- 
tion, or evacuated by the eflTorts of nature, there 
yet remains the alternative of making an opening 
into the chest, and thus creating an artificial out- 
let for the discharge of the matter. This consti- 
tutes the operation o{ paracentesis thoracis, or, as 
it is sometimes called, the operation of empyema. 

This operation is at all times easy of execution, 
productive of little pain to the patient, generally 
followed by immediate relief, and has in nume- 
rous instances been crowned with complete suc- 
cess. Sprengel, in his erudite work on the his- 
tory of medicine, en\imorates amongst the advo- 



cates of this operation the names of almost all the 
most distinguished medical and surgical writers, 
from Hippocrates downwards, many of whom 
from their writings appear to have practised this 
operation with a degree of confidence and success 
unknown at the present day. The same v^ork 
likewise contains brief notices of such avast num- 
ber of cases in which the resuU was favourable, as 
are more than fully sufficient to establish the fre- 
quent success of this operation. 

If, however, we reflect that empyema is gener- 
ally the eflfect of a pre-existing disease of the lungs 
or pleura, and that the effect of the operation is 
merely to remove the effused fluid, while the dis- 
ease of the solids still remains behind, we must be 
prepared to expect that this operation should often 
fail of success. 

Another cause of the fiiilure of this operation is 
the condensed condition of the lung, which, from 
long compression, has lost its expansibility and 
elasticity. In consequence of this it slowly regains 
its natural dimensions; and in some cases the un- 
folding of the lung is still further opposed by the 
formation of false membranes on its surface. The 
space thus left between the lung and the walls of 
the chest by the evacuation of the fluid is filled 
with atmospheric air, which rushes in through 
the wound, and excites a purulent discharge, so 
copious as to exhaust the patient's strength, while 
the inflammation it causes in the suppurating sur- 
face cannot produce the obliteration of the cavity, 
the parts being still too far apart to be aggluti- 
nated. 

It sometimes happens, also, that the operation 
is followed by the decomposition of the matter 
discharged from the wound, which assumes a 
dark ichorous appearance, and exhales an odour 
insupportably fetid. This alteration in the sensi- 
ble qualities of the secretion is generally attributed 
to the irritating effects of the atmosphere on the 
imperfectly organized membranes with which the 
pleura is lined. 

These considerations should certainly make us 
cautious in having recourse to the operation so 
long as there remained a reasonable prospect of 
the fluid being removed by other means, but 
should not deter us from the practice in those 
cases where other remedies had been tried and 
found ineffectual, or where the urgency of the 
symptoms precluded all reasonable prospect of 
relief from their use. In such cases the sooner the 
operation is had recourse to the better ; for, as 
Willis tritely observes, " dummodo vires corista- 
bunt prsestat remedium anceps experiri quam 
nullum." (De Empyemate, p. 97.) Our greatest 
modern authority on the subject of pulmonary 
diseases, Laenncc, was a great advocate for the 
performance of the operation. (See Translation, 
p. 191.) 

Notwithstanding these strong attestations in its 
favour, the operation has latterly fallen very much 
into disuse, as much, perhaps, from the uncer- 
tainty of the signs of empyema as from any expe- 
rience of its general inutility or danger. Now, 
however, that the diagnosis of this disease no 
longer presents the same difficulties as it did ror- 
merly, and that we are enabled to recognize at 
any early period of tlieir progress, those casea 
which may be benefited by the operation, and 



36 



EMPYEMA. 



tliereby have it in our power to operate early, and 
consequently with better chance of success, it is 
probable that the operation will be employed more 
frequently and more successfully than it has 
hitherto been.* Within the last year the opera- 
tion has been twice performed by the advice of 
Dr. Marsh, of Dublin, and in both instances the 
success of the operation has been complete. Dr. 
Crampton, and Mr. Crampton, the surgeon-general 
of Ireland, have also communicated to the writer 
the particulars of three cases from their practice, 
in which the operation was equally successful. 

The result of these cases is highly favourable 
to the more general adoption of the practice, and 
fully confirms the observation of a modern author, 
« that it is a measure which has frequently proved 
successful, and that too in a disease which is gen- 

* We learn that in London the operation has been 
repeatedly performed, more particularly under the direc- 
tion of Dr. Tliomas Davies. For the following tabular 
view we are indebted to the kindness of that intelligent 
physician, by whose advice the operations were per- 
formed. Dr. Davies has requested us to state thai five 
of the cases belonged to Dr. 13. Biibington, and one to Dr. 
Stroud ; Dr. Davies was only called into consultation by 
these gentlemen. 



Nature of the 
case. 



Empyema 



Operator. 



!Mr. Stukcly, late 
Apothecary to the 
Infirmary for Dis- 
eases of the lungs 
S Mr.Martin, Surgeon, 

( R.N 

Mr. Headington 

Mr. John Scott 

Mr. Herring, Apothe- 
cary to the Infir- 
mary for Diseases 

of the Lungs 

Mr. Kiernan 

Dr. B. Babington 

Mr. Skey ...' 



Total Empyema 



Event of the 
cases. 



Pneumotho- 
rax, with 
effusion . . 



Mr. Headington 



Mr. John Scott 
Mr. Kiernan .. 
Mr. Smith 



Total pneumothorax 



Hydrothorax ... 




•'■ 


•"' 


I 


Mr. Kingdom 




Total hydrothorax . .1 " | " 


3 


Grand total . . 
Number of cases .... 23 


8 


1 14 



JVotcs by Dr. Davies. — }. The result of the operation 
in the cases of empyema is very satisfactory ; eight of 
the patients out of ten having recovered. Of these, five 
were under six years of age, one was between eighteen 
and nineteen, and two were above twenty-five. 

2. All the cases of pneumothorax were complicated 
with tubercular diseases of the lungs, a circumstance 
whiih, of itself, prechided a favourable result. All the 
patients were beyond twenty years of age. 

3. All the cases of hydrothorax were the consequences 
of disease of the heart. Although none of the p.atients 
recovered, they were all relieved by the operation for a 
corsiderable time. — Editors. 



erally, if not tilways, beyond the influence of me- 
dicinc, and too often beyond the power of nature 
to remove." (Forbes's Original Cases, &c., p. 

258.) , . . . 

There are two cases in which this operation is 
particularly indicated:—!. In acute empyema, 
when the breatliing is extremely oppressed, and 
the effusion goes on rapidly increasing. In this 
form of the disease, however, it is always advisa- 
ble, if possible, to defer the operation until the 
inflammatory symptoms shall h:r. o subsided, as it 
will be of little advantage to evacuate the con- 
tents of the pleura so long as that membrane con- 
tinues in such a state of inflammation as to re- 
produce the effusion. When, however, the difH- 
culty of breathing is so great as to reiider the 
immediate performance of the operation necessary 
in order to prevent the risk of suffocation, it is 
probable that this object may be sufficiently at- 
tained by making small punctures with a trochar 
from time to time, when the breathing becomes 
much oppressed, and drawing ofT only so much 
fluid as is necessary to diminish the pressure ex- 
ercised by the effusion on the op[)osite lung. By 
operating in this way the breathing will be imme- 
diately relieved, and the danger avoided of admit- 
ting the atmospheric air into contact with an 
already highly inflamed pleura. Perhaps, too, 
this partial abstraction of the effusion may at once 
aid the absorption and accelerate the conversion 
of the false membranes; such, at least, is the 
opinion of Laennec, (Op. cit.) 

When acute empyema succeeds to penetrating 
wounds of the chest, it is advisable not to operate 
before the orifices of the wounded vessels are so 
firmly closed as to prevent any danger of a recur- 
rence of hemorrhage ; for this reason Baron Lar- 
rcy recommends that the operation should not be 
performed in such cases before the seventh, or 
deferred after the eleventh, or, at the farthest, the 
fourteenth day. 

2. The second case in which this operation is 
particularly indicated, is in those cases of chronic 
empyema where the ordinary means for promot- 
ing absorption have been tried and found ineffec- 
tual. In such cases it is impossible to lay down 
any general rule as to the precise period at which 
the operation should be performed, as that point 
must be determined by the state of the constitu- 
tion, the urgency of the symptoms, and the extent 
of the eflusion, rather than by the date of its for- 
mation. So long as any reasonable prospect can 
be entertained of the disease being removed by 
the efibrts of nature, or the influence of medicine, 
the effects of remedies should of course be tried, 
but at the same time it should be borne in mind 
that this disease is generally, if not always, be- 
yond the power of medicine to relieve, and that 
the persisting in the employment of remedies 
which experience has so often proved ineffectual, 
can only tend to diminish the ultimate chance of 
success by deferring the operation, as is too often 
done, until the effusion becomes so extensive, and 
the patient's strength and constitution so ex- 
hausted, as almost to preclude the possibility of 
recovery. 

It has been proved by experience that the ope- 
ration IS frequently successful when the patient is 
young and of good constitution, the efi'usion mod- 



EMPYEMA. 



37 



crate in quantity, recently formed, and unaccom- 
panied with organic disease of the lungs. On the 
other hand, the prospect of success diminishes 
considerably when the effusion is very extensive, 
of long standing, and accompanied by symptoms 
of confirmed hectic. 

The copiousness of the effusion, however, 
though it generally diminishes the chances of re- 
covery, does not necessarily preclude the success 
of the operation. Baron Larrey operated success- 
fully in a case where the effusion amounted to 
fifteen pints ; Dr. Hawthorne's patient lost twenty 
pints of pus during the first twenty-four hours ; 
and in Dr. Archer's successful case, already quoted, 
eleven pints of fluid were drawn oif at the first 
evacuation. The same remark is likewise appli- 
cable to the length of time during which the em- 
pyema has existed, and to the symptoms of hectic 
with which it is accompanied, as there are several 
cases on record where the operation was success- 
fully performed under those unfavourable circum- 
stances, (Dictionnaire des Sciences Medicales, art. 
Empyemc. 

In the numerous class of cases where empyema 
is complicated with pneumothorax from the rup- 
ture of a tuberculous abscess in the lung, the 
chance of any permanent advantage from the 
operation must necessarily be very small, in con- 
sequence of the incurable nature of the original 
disease : in such cases, indeed, little else can be 
hoped for from the removal of the effusion than a 
temporary alleviation of suffering, or the prolonga- 
tion of existence for a few weeks or months at 
the utmost ; such, at least, is the conclusion that 
we have formed, after having witnessed tlie pro- 
gress and fatal termination of eighteen cases of 
this nature, in five of which the operation was 
performed with no better success than that just 
described. (See Pxeumotuorax.) Laennec, 
however, is of o[)inion that <' we must not aban- 
don all hope of cure, even when there exists so 
serious a complication as this, provided there be 
no evidence of cavities in the opposite lung." (Op. 
cit.) 

The complication of pneumothorax does not 
seem to fjrm so serious an objection to the opera- 
tion, when not coupled with the presence of tu- 
berculous abscesses in the lungs, as appears from 
its having been successfully performed in several 
, cases where the sound of fluctuation, audible in 
the chest, suHiciently proved the coexistence of a 
gaseous and liquid effusion. Dr. Archer's remark- 
able case of this kind, published in the Transac- 
tions of the Association, has already been alluded 
to. A still more remarkable case of empyema 
with pneumothorax, terminating successfully by 
operation, is related by Dr. G. Hawthorne, in 
the Edinburgh Medical and Surgical Journal, 
No. 61. 

Neither does the existence of a fistulous pas- 
sage through the lungs necessarily preclude the 
success of the operation, as is evident from those 
cases where it was performed after the empyema 
had burst internally into the bronchi, and yet the 
communication thus formed through the lung did 
not af)pear in the least to impede the patient's 
iltimate recovery. Le Dran relates a case on 
which he operated for empyema where " the in- 
jection of a small quantity of mel rosarum and 



barley-water through the wound excited coughing, 
and part of it passed off by the mouth, mixed 
with pus ;" thus clearly proving the existence of a 
fistulous passage through the lung, notwillistand- 
ing which the patient recovered completely. Seve- 
ral similar cases are quoted in the Dictionnaire des 
Sciences Medicales, from the writings of MM. 
Jaymes, Robin, and Bacqua. In these cases, how- 
ever, the empyema must in all probability have 
been circumscribed, and the lung retained by ad- 
hesions in contact with the walls of the chest 
around the circumference of the wound ; or else 
the injection, instead of entering the lung, would 
have fallen to the bottom of the pleura. 

It is unnecessary here to enter into any minute 
description of the mode of performing the opera- 
tion, as this is described in all treatises on the 
subject and in all systems of surgery ; but the 
reader is more particularly referred to the works 
of Le Dran, Richter, Sharp, C. Bell, Larrey, and 
Boyer, [Ferguson, and Listen,] where he will find 
all the necessary information. 

[For the removal of the fluid, Drs. Prichard and 
Babington have recently recommended instru- 
ments, which are described under Ascites, (page 
188,) — and should any doubt exist as to the pre- 
sence of fluid, a grooved or exploring needle, as 
advised by Dr. Thomas Davies, (^Lectures on Dis- 
eases of the Lungs, S(c., Lond. 1835,) may be 
passed into the chest, by which not only the pre- 
sence but the character of the effused fluid may 
be safely determined.] 

Authors make a distinction in the operation 
according as the matter points externally or not. 
The former they term the operation of necessity, 
from its site being necessarily fixed : and the lat- 
ter the operation of election, from the surgeon 
being at liberty to select at what part of the chest 
he makes his incision. 

In the empyema of necessity, as it is termed, 
when the matter points externally, the sooner an 
incision is made into the tumour the better, as 
there is no chance of the matter being removed 
by absorption, and the consequence of delaying 
the operation has too often been the formation of 
long sinuous passages through the parietes of the 
chest and abdomen, and caries of the ribs. In- 
deed this operation is much more generally suc- 
cessful than that performed at the place of election, 
which no doubt arises from the circumstance that 
those empyemas which point externally are almost 
invariably circumscribed, and confined to a small 
extent of the pleural sac. 

When no tumour appears, to fix the site of the 
operation, the place of election generally recom- 
mended by surgeons in this country is between 
the sixth and seventh true ribs, where the indigi- 
tations of the serratus major anticus muscle meet 
those of the obliquus externus. Laennec prefers 
the space between the fifth and sixth ribs. " Many 
reasons (he says) point out this spot as the best 
suited for the operation : for instance, we know 
that the upper lobe adheres to the ribs more fre- 
quently than any other part of the lungs, and that 
the lower lobe is frequently attached to the dia- 
phragm, while adhesions very seldom exist at the 
central part of the chest ; and even should there 
chance to be any old adhesions in this point, they 
may be readily and certainly discovered by somn 



38 



EMPYEMA, 



remains of respiration over their site, and the place 
of the operation may then be varied accordingly : 
besides, we know that the thickest false mem- 
branes exist at the junction of the diaphragm 
with the walls of the chest, and that at the right 
side an enlarged liver frequently reaches as high 
as the sixth or even as the fifth rib;" in which 
case, when the operation is performed in the usual 
situation, the instrument, instead of entering the 
chest, would transfix the diaphragm and penetrate 
the abdomen ; there are several cases on record 
of the operation having been frustrated by this 
accident. Laennec informs us that in a case of 
pleuro-pneumothorax, after making an incision 
through the integuments between the fifth and 
sixth ribs, he thrust the trochar, as he thought, 
into the thorax, and was much surprised to find 
that no fluid followed its introduction ; but on 
dissection he discovered that the instrument had 
entered the cavity of the abdomen, after transfix- 
ing the diaphragm, which had been thrust up into 
the cliest by an enlargement of the liver, and had 
contracted a firm adhesion to the seventh rib. 
(Op. cit.) A similar accident happened to La 
Motte, (Traite complet de Chirurgie, vol. ii. obs. 
77, p. 292 ;) and Solingen saw the diaphragm 
wounded by the introduction of a canula after the 
operation, which was performed between the first 
and second of the false ribs. (HandgriflTe der 
Wundarzney, Th. ii. Kap. i. p. 175.) The only 
object of operating so low down is to make the 
opening at the most dependent part of the chest 
for the more complete evacuation of the effusion ; 
but this ol)ject may be sufficiently attained by 
operating between the fifth and sixth ribs, which 
may in fact be made the most dependent point of 
the chest, by causing the patient to lie, as he gene- 
rally feels disposed to do, on the diseased side. 
The danger of wounding the intercostal artery 
may be avoided by making the incision close to 
the superior edge of the lower rib. [See on this 
subject Stokes on the Chest, Amer. edit. p. 483, 
Philad. 1844. Recently the writer directed the 
operation to be performed in a case of chronic 
pleurisy. The operator, in accordance with the 
recommendations of Dr. Ferguson, (^A System of 
Practical Surgery, Amer. edit. p. 530, Philad. 
1843,) selected the seventh rib, a little in front of 
the angle, for the place of puncture, but no fluid 
escaped. On repeating the operation immedi- 
ately above the fifth rib, half way between the 
spine and the sternum of the right side, he was 
completely successful.] 

Wlien the incision is carried through the pa- 
rietes of the chest and the false membranes with 
which they may be coated, a rush of fluid is im- 
mediately expelled by the pressure of the parietes, 
and continues to flow in an uninterrupted stream 
until the surface of the fluid falls to the level of 
the wound, after which it issues in a scries of in- 
terrupted jets corresponding to the motions of the 
diaphragm ; for as this muscle descends in inspi- 
ration, the fluid which lies on its surface sinks 
along with it, and the atmospheric air rushes in 
to fill up the space created by its descent : again, 
as the diaphragm rises in expiration, the incum- 
•lent fluid is elevated to the level of the orifice, 
and issues in a jet from the wound ; this alternate 
sucking in of air and expulsion of fluid continues 



until the quantity of matter is dinunished so as 
no longer to rise to the level of the wound during 
expiration, after which each movement of the dia- 
phragm is followed by the alternate introduction 
and expulsion of air, so long as the wound is al- 
lowed to remain open. Many reasons, however, 
render it inexpedient to continue the operation to 
this period. The sudden removal of .so large a 
quantity of fluid frequently produces such a sho:k 
to the nervous system as throws the patient into 
an alarming state of collapse ; the withdrawing 
so great a degree of pressure from the heart and 
large blood-vessels and from the opposite lung 
must likewise derange materially the functions of 
these important organs, and consequently oppose 
the success of the operation ; and another inju- 
rious consequence of protracting the operation 
until all the fluid has been evacuated is, that the 
parietes of the chest are unable to accommodate 
themselves to the space which is thus left unoc- 
cupied, and which must consequently be filled 
with atmospheric air. 

For these reasons it is advisable to close the 
wound before the fluid begins to issue in an in- 
terrupted stream, and to repeat the evacuation at 
longer or shorter intervals, according to the extent 
of the ef!"usion and the urgency of the symptoms. 
In general, the removal of twenty ounces of fluid 
at a time will be found sufficient to relieve the 
breathing, (as this effect is produced, at least in 
the first instance, by diminishing the pressure on 
the opposite lung, and not by restoring the func- 
tions of the organ at the diseased side,) and an 
interval of forty-eight hours may be allowed to 
elapse before the wound is again opened. When, 
however, the effusion is verj' extensive, and the 
breathing not sufficiently relieved b)' the removal 
of the quantity above specified, the fluid may be 
allowed to flow for some time longer, or the evacu- 
ation may be repeated at shorter intervals. When 
the principal part of the effusion has been remov- 
ed in this way, a large poultice may be apphed 
over the wound, and the remainder of the fluid 
allowed to escape as fast as it is secreted. 

By this method of gradually removing the effu- 
sion, we diminish the shock to the nervous sys- 
tem, reheve the thoracic viscera gradually from 
the pressure of the accumulated fluid, and prevent 
the introduction of air into the thorax, until the 
parietes have had time to accommodate themselves 
to the diminished volume of their contents, and 
by their mutual approximation diminish, to the 
utmost, the space left by the evacuation of the 
effusion. 

The following measurements taken from a pa- 
tient of twelve years old, who lately underwent 
this operation, will serve to illustrate the diminu- 
tion which takes place in the capacity of the dis- 
eased side by the falling in of its osseous parietes: 



Circumference Circumference 
of the dheaaed of the «iound 




9th day alter the ojicration .'".■.■.■.■. ]3 9 \\ \ 

Thus, in the space of nine days, the circumference 
of the diseased side diminished nearly three inches. 



This contraction of the 



osseous parielcf, aided by 



EMPYEMA — ENDEMIC DISEASES. 



39 



the ascent of the diaphragm, and the protrusion 
of the mediastinum from the increased dilatation 
of the op[)osite lung, reduced the cavity of the dis- 
eased side to so small a compass, especially in 
young subjects, whose ribs are susceptible of a 
much greater degree of motion than those whose 
cartilages are ossified, as to leave very little space 
unoccupied for the reception of air. This space 
is subsequently filled up as the lung gradually ex- 
pands and rises into contact with its parietes : 
this, however, is always a very slow process, as 
several weeks in general elapse before the slight- 
est trace of respiration can be perceived in the dis- 
eased side; as the lung continues to expand, the 
contraction of the side gradually diminishes, until 
at length the lung resumes its original dimensions 
and the contraction of the side disappears altoge- 
ther. In some cases, however, the dilatation of 
the lung is never complete, and the side remains 
permanently contracted in consequence. Lastly, 
there are some cases in which recovery takes 
place, although the lung never expands so as to 
fill the space left by the evacuation of the empye- 
ma. In these cases the wound made by the 
operation is converted into a permanent fistula, 
through which the atmospheric air is allowed to 
enter, and the matter secreted by the walls of the 
cavity to escape, without producing any very con- 
siderable inconvenience to the patient's health. 
Several cases of this termination of the operation 
are recorded by Plater and Schenkius, and by MM. 
Lefacheux and Audouard. (See Empyetne, in 
the Dictionnaire des Sciences Medicales.) But 
perhaps tlie most remarkable case of this kind on 
record is that recently published by Dr. Wendel- 
stadt of Hersfield, who underwent the operation 
of paracentesis for empyema in his own person, 
thirteen years ago, since which time the wound 
has remained open, and the fluid has been drawn 
off twice every day, sometimes so much as 
three or four ounces daily. Three years ago, be- 
ing anxious to ascertain the dimensions of the 
cavity which existed in the thorax, he found that 
it was capable of containing a quart of warm 
water. The diseased side is much contracted, 
and does not move at all in respiration, yet he 
can blow the flute, and walk faster than many 
persons who are in perfect health, and for several 
years he has resumed the active discharge of his 
professional duties. (Journal der Praktischen 
Heilkunde, Januar. 1831.) 

Various expedients have at different times been 
contrived for extracting the air out of the pleura, 
with the view of removing the pressure from the 
lungs' surface, and thereby facilitating their ex- 
pansion. A variety of syringes have been con- 
trived for this purpose, and recently M. Laennec 
lias proposed to apply a piston-cupping-glass over 
the wound immediately after the discharge of the 
liquid, and to produce a vacuum in the chest more 
or less quickly, continuously and completely, ac- 
cording to the effects. If this suggestion were to 
be put in practice, care should be taken to avoid 
exhausting the air so far as to suck out a portion 
of the lung through the wound, as happened to 
the writer of this article, when trying the efficacy 
of the proposed plan on a dog. Another objec- 
tion to the success of this contrivance is the diffi- 
culty of preventing the air from again rushing in 



through the wound the moment that the exhaust- 
ing glass is removed. 

After all, it appears very doubtful whether the 
admission of air into the pleura is really as dan- 
gerous as IS generally supposed, or whether the 
quantity of air which is contained within the 
chest affords any sucli serious obstacle to the ex- 
pansion of the lung, that its removal may not be 
safely entrusted to the power of the absorbents ; 
as the experiments of Nysten, and more recently 
those of Speiss, (De vulneribus pectoris penetran- 
tibus,) have fully proved that air introduced into 
the pleura is invariably removed by absorption in 
the course of a few days. 

In those cases where the introduction of air 
produces an unhealthy discharge from the wound, 
the practice of using injections may be had re- 
course to with advantage for the purpose of cor 
reeling the morbid action of the suppurating sur 
face, and removing the putrescent qualities of 
the discharge. Willis relates a remarkable in- 
stance of the efficacy of injections in such cases 
The fluid drawn off at the time of the operatior 
was perfectly inodorous, and continued free from 
smell for the first three days ; after which, when- 
ever the wound was opened, a smell, which he 
describes as " odor teterrimus, cloaca cujusvis 
maxime putentis ftetorem superans,' infected the 
whole chamber; but by the repeated use of injec- 
tions, the horrible fetor of the discharge was en- 
tirely corrected, and the patient ultimately reco- 
vered. (De Empyeinate, p. 98.) M. Freteau 
records another case in which, shortly after the 
operation, the discharge assumed a dark ichorous 
appearance, and exhaled a gangrenous smell ; but 
by persisting in the use of injections for twenty 
days, the matter discharged from the wound as- 
sumed a healthy appearance, and lost its disagree- 
ble odour. Willis was in the habit of using a 
decoction of various aromatics and stimulating 
herbs for this purpose. MM. Freteau, Billery, 
and Audouard recommend the decoction of cin- 
chona as less irritating than that used by Willis, 
and equally efficacious. (Diet, des Sciences Med. 
art. Einpycme.^ A weak solution of the chlo- 
rate [chloride] of lime will probably be found to 
act still more efficaciously as an antiseptic. [But 
it need scarcely be said, that all such applications 
must be used with the greatest caution, for fear 
that inflammatory action may be set up, which 
may not be easily subdued.] 

R. TOWNSEND. 

ENDEMIC DISEASES.— E^^emt'c is a word 
applied to those diseases which occur among the 
inhabitants of a particular place or country, in 
consequence of something local or peculiar in the 
air, or water, or soil, or in the food and habits of 
the people. Hippocrates has left a treatise, which, 
though containing some crude observations, is a 
model that has been too much neglected by me- 
dical writers. His book De Aeribus, aquis, locis, 
according to Haller, is composed in a style, and 
contains reasoning, worthy of its great author. If 
we except the Dissertation on Endemic Diseases, 
by Hoffmann, we have few works written expres.s- 
ly on the subject. Yet it is one which we might 
suppose would have engaged the serious attention 
of physicians in all ages. 



40 



ENDEMIC DISEASES. 



The knowledge of those peculiarities in climate, 
soil, elevation, and site of dwelliiip;, and especially 
in food, drink, and habits ; as well as of the moral 
and physical varieties which are found to coexist 
with certain forms of disease, in any part of the 
human family, is a branch of medical science that 
seems to include some of its essential principles. 
It is a field that well deserves to be further culti- 
vated ; and as we are now becoming better ac- 
quainted with different parts of the world by 
means of more accurate and intelligent observers, 
it is to be presumed that the data will soon be 
multiplied, from which, upon comparison of one 
country with another, many useful practical hints 
may be deduced, and the real causes of some hid- 
den things in this department of our science as- 
certained. Of late years, indeed, much to the 
credit of our professional brethren both in the east 
and west, many excellent monographs on the me- 
dical topography of different places have appeared. 
An interesting article, pointing out these and 
other works on the subject, is to be found in the 
sixteenth volume of the Edinb. Medical Journal, 
ni the editor's learned review of the " Medical 
Topography of Upper Canada, by John Douglas." 
But it may be truly said of endemic diseases, ge- 
iKTally, in the words of that able review, that " a 
complete work on the subject is one of the greatest 
desiderata in our professional literature." 

It is needless to expatiate on those things which 
are obvious to every enlightened observer. As in 
the body, different effects result from the dry and 
bracing wind of the mountain, compared with 
those from the moist and sluggish air of the val- 
ley ; so, as regards the mind, the observation of 
the poet is philosophically true, — 

•' An iron race the mountain cliffs maintain, 
Foes to the gentler manners of the plain." 

Gray. 
"La terra molle e lieta e dilettosa 
Simili a se gli abitator' produce." 

Tasso. 

But as the physical effects are liable to be varied 
by climate, elevation, temperature, winds, and the 
vicinity of wood and water, as well as by the 
quality of food and drink and the habits of life ; 
so the moral effects (if not indeed also the physi- 
cal) may be varied by the state of liberty or op- 
pression, of sloth or activity, of comfort or wretch- 
edness, of cleanliness or filth, of mental apathy or 
cultivation, in which our fcllpw-creatures in any 
part of the world may happen to be placed. 
From all these controlling circumstances need we 
wonder that diseases should assume such varied 
appearances ? or that many who are hving toge- 
ther in the same community, and even born on 
the same soil, should escape some of the evils to 
which their less fortunate neighbours are liable ? 
If such escape, there is less cause to wonder that 
entire strangers should escape also. This in fact 
is often the case. And when the inhabitants of 
any particular country or place are especially Hable 
to some form of endemic complaint, they are 
found to be for the most part exempt from other 
serious affections. It was a proposition of Dr. 
James Sims, a physician of acute observation, that 
if a patient on the verge of pulmonary consump- 
Ibn could be taken into a fenny country in the 
height of the season, so as to contract a severe 
nu'ue, there would be little doubt of the phthisical 



symptoms being at once arrested. The natives of 
a country often become inured by habit to circum- 
stances which very soon exert a dangerous influ- 
ence on strangers. The marsh miasmata of the 
tropics are more pernicious to strangers than to 
the natives. The cold winds of the northern 
climates most frequently affect the natives of 
Africa and the Indies with mortal pulmonary 
inflammations. It is demonstrated in countries 
which are inhabited by different races of men, as 
the negroes and Malays, the Americans and 
negroes, that the same circumstances do not pro- 
duce the same morbid effects on both classes. It 
has been frequently remarked that the water of 
the Seine produces a diarrhoea in every one except 
the Parisian accustomed to the use of it. The 
same treatment will not be required for the same 
diseases, or rather for diseases called by the same 
name, in different places and seasons, as in moun- 
tainous and in low situations, in summer and in 
winter, in hot and in cold climates, in affluent 
stations of society and in indigent. Baglivi says 
that at Rome ulcers of the legs are almost incwra- 
ble, while wounds in the head heal without any 
trouble. Cleghorn tells us of an old proverb, that 
" Minorca is good for tlie head but bad for the 
shins." In France it is remarked that ulcers of 
the legs are more easily cured at Montpellier, and 
those of the head at Paris. (See Diet, des Sc. 
Med. art. Endemigue.) 

Hippocrates and Celsus both remark that ob- 
stinate ulcers of the legs frequently exist in those 
who are affected with enlargement of the spleen. 
[Clcghor?!, Op. cit. p. 71.) The cretin of the 
close gorges of the Vallais loses his stupidity in 
the dry and sharp air of the high neighbouring 
mountains, while the brisk mountaineer experi- 
ences less of hemorrhage and of acute disease in 
the heavy and cloudy air of the valleys. (Yirey.) 

It is an old observation that hemorrhages, acute 
diseases, and inflammatory affections, are more 
common in dry and elevated situations, especially 
if these are much exposed to the north wind. 
The contrary may be expected in opposite situa- 
tions, where the "plumbeus auster" lends its aid 
to weaken the body and depress the spirits. 

It would undoubtedly be a useful work to trace, 
on an enlarged scale, a connected outline of the 
endemic diseases in different countries, with their 
topography, and the food and habits of the people. 
But we must regret that the statements or observa- 
tions (within our reach) that relate to the sup- 
posed causes of such diseases, are many of them 
too loose and partial for scientific generalization. 
With such materials, all that can be proposed at 
present is a very general notice of some of the 
leading well-attested facts belonging to the most 
remarkable diseases that usually come under this 
denomination, and for obvious reasons every thing 
relating to their symptoms and cure must be com- 
mitted to other articles of this work. 

1. Inter mitteiit Fever. — No observation is 
more general than that ague is endemic among 
the inhabitants of places where marshes abound, 
and in seasons, as the spring and autumn, when 
the effluvia arising from them are more active, and 
the body perhaps more liable to be affected by 
their peculiar poison. There are few marshy 
countries, in temperate and tropical climates, in 



ENDEMIC DISEASES. 



which intermittent fever is not known. The con- 
nection, therefore, between them does not depend 
on a UniUed, but a comprehensive induction of 
facts; the truth is abundantly confirmed. Ague, 
indeed, sometimes appears where the influence of 
marsh effluvia cannot be traced ; and the term 
malaria has been brought into modern use to 
denote a morbific atmosphere, arising from the 
soil, capable of producing intermittent fever, in 
which marsh miasmata, properly so called, are 
supposed not to constitute an essential part. 
Many facts would seem to countenance this opin- 
ion, as well as that which assigns to malaria the 
production of continued fever under certain cir- 
cumstances. In the metropolis we have known 
persons attacked with ague, mostly however of an 
irregular type, by working in damp cellars. In 
temperate climates, under ordinary circumstances, 
the milder forms of the disease appear, and these 
in the spring, as the quotidian and tertian. The 
quartan, more obstinate and protracted, usually 
appears in autumn. In Sydenham's time, and 
even in that of Fothergill, the quotidian of spring 
became continued fever in summer; while the 
simple continued fever of summer often changed 
to a malignant type in autumn. These were sim- 
ple observations at a time when systematic ar- 
rangements had not put physicians in trammels. 
But now, lest we should be guilty of medical her- 
esy, we must not insinuate that ague can change 
into continued fever, and non-contagious fever into 
contagious typhus, either in an individual case or 
in the course of the year ! 

It has been commonly observed that the spleen 
suffers more in cases of protracted intermittents 
in temperate climates, and the liver in tropical. 
Nevertheless, Dr. Jackson tells us of enlarged 
spleen after such fevers in the West Indies : Cleg- 
horn noticed the same in Minorca ; and we have 
the testimony of W. Twining, that this organ is 
often found diseased from this cause, in Bengal 
and all the low districts of Hindostan, (Calcutta 
Medical Trans, vol. iii. p. 354.) 

When tropical heat is added to the influence 
of marsh effluvia, then we have the various shades 
of intermittent, remittent, and even continued 
fever, passing sometimes into each other by al- 
most imperceptible gradations, and complicated 
more or less with bilious symptoms. When in- 
temperate seasons, deficient or unwholesome food, 
and animal filth, are superadded to the causes 
above mentioned, and acting upon a condensed 
population, the highest grades of pestilential fever 
are often exhibited, as the plague of Egypt and 
the Levant, the pestilential fever of Spain, and 
the yellow fever of America and the West In- 
dies. 

When marshy land is brought to a very dry 
state in summer, after long-continued drought, 
ague is often but little known in the vicinity ; but 
the first heavy shower after the drought will some- 
times give rise to it. And on the contrary, in a 
wet season, while much water is lying upon the 
marshes, the disease is rare; but in proportion as 
they become dried to a certain point, the mias- 
mata are found to be active, according to the de- 
gree of heat, the season of the year, and the state 
of the population. A cei«»ain quantity of mois- 
ture, therefore, seems to be necessary upon the 

Vol. II. — 6 » * 



marsh, in order that the miasmata may be disen- 
gaged ; and of vapour in the atmosphere to con- 
vey them to a distance ; while a superabundance 
either prevents their evolution, or entirely absorbs 
them. 

Notwithstanding that the notion has been ridi- 
culed by a few, there can be little doubt that cur- 
rents of air will sometimes waft the efliuvia to a 
great distance, so as to produce intermittent fever 
in places otherwise healthy ; and some facts would 
seem to show that hills of a certain elevation in 
the vicinity of marshy grounds have a sort of 
attraction for the miasmata, and are almost as 
unwholesome as the plains.* But it is upon a 
different principle that hilly grounds, in some 
cases, become more unhealthy than the plains. 
The British army in 1809 found that the hilly 
sides of the ravines in Portugal, after heat and 
rain, exposed the soldiers to a most destructive 
remittent, while the overflowed swamps below 
were more than usually free from disease : " and 
such," says Irvine, " is frequently the case on the 
lofty ridges of Sicily, when their fiumari, or water- 
courses, which are ordinarily dry, and used for 
roads in the summer months, are filled and inun- 
dated with sudden torrents of rain. For here the 
malaria changes its station, and quits the over- 
flowed low lands for the heights of the primitive 
hills. (Good's Study of Medicine, vol. ii. p. 166.) 

Plantations of trees have been known to inter- 
cept marsh miasmata, and thus to prevent their 
injurious effects upon the inhabitants at a short 
distance ; and for the same reason it is found that 
the site of a dwelling should not be too near such 
plantations. " It is wonderful," says Dr. Fergu- 
son, (loc. cit.) " to see how near to leeward of the 
most pestiferous marshes, in the territory of Gui- 
ana particularly, where these trees abound, the 
settlers will venture with impunity to place their 
habitations, provided they have this security ; 
though every one is fully aware that it would be 
almost certain death for an European to sleep, or 
even to remain after night-fall, under the shade 
of the lofty trees that cover the marsh, at so short 
a distance." (Med. Chir. Eev., Dec. 1821.) 

There is something curious and not easily ex- 
plained in the circumscribed locality of intermit- 
tent fever in certain places. Perhaps, if the pre- 
valence of winds and the situation of such places 
as to exposure and wood and water, &c., were 
taken into account, the difficulty might be in part 
removed. A late writer on malaria states, that on 
the high Dover road, in Kent, not far from Ko- 
chester, some of the people living on one side of 
the road were attacked with ague, while on the 
other side all escaped. 

It is amply proved that marsh effluvia exert far 
more pernicious influence upon the body during 



* Medico-Chir. Review, vol. ii. p. 59], Dec. 1821 ; Dr. 
Ferguson on Marsti Poison. Dr. Robertson fully co,<. 
firiiis the observation of Dr. Ferguson, relative to the 
exposure of the inhabitants of liigh situations in the 
vicinity of marshy grounds to the etiects of t lie miasmata. 
(iMeU. itepos. vol. i. p. 3t)7.) He knew people to lie se- 
verely atfected by this cause, who hail ncjt been for some 
time without the walls of the castle of Santa Liarbara, at 
Alicante, 800 feet above the sea-shore; while at the 
same time, persons living on a level with the sea, and 
exposed to all the sources of marsh miasma, escaped 
every attack of fever. He considers that the high 
grounds present an impediment to the free dispersion o' 
the exhalations through the atmosphure. 



42 



ENDEMIC DISEASES. 



the state of sleep, or even when it is exposed to 
them in the night air without sleep. It has also 
been ohserved, in illustration of the ague-giving 
qualities of the east-wind, that some time, even 
days or weeks, after an exposure to marsh mias- 
mata has taken place without producing any per- 
ceptible bad effect, the casual blowing of the east- 
wind has at once fixed an attack of ague. Sea- 
water flowing over marshy ground, cspleris pari- 
bus, seems to give rise to more pernicious effluvia 
than fresh water. The bogs or peat-mosses of 
Scotland and Ireland, on the other hand, do not 
appear to generate ague. 

Dr. [Sir James] Clark, in his late work " On 
the influence of Climate," states, that with regard 
to Rome, at the present time, " a certain period of 
residence in the malaria site is necessary, in gene- 
ral, to prepare the body for its attack ; and that 
there is no reason for the fear commonly enter- 
tained of a sudden attack of malaria from simply 
passing quickly through a malaria district." " The 
German, French, and English artists were more 
frequently attacked with fever the second or third 
years of their residence at Rome than the first." 
But the situation of this city will not bear an ex- 
act comparison with that of a pure marshy district. 

Seamen, who after a long voyage venture to 
land on a marshy shore in the height of the Rea- 
son, too often find that if they remain a single 
night on land they are attacked by the endemic 
fever almost immediately. Hence it has often hap- 
pened that vessels coming to a maritime city, on 
the eve of a pestilential visitation, although with 
clean bills of health, have been among the fir^t to 
show s'gns of disease in some of the crew , and 
the fact has been eagerly laid hold of to counte- 
nance the suspicion that contagion from the vessel 
gave rise to the distemper; for it need not be told 
that mariners who have been long at sen are very 
susceptible of morbid impressions from a vitiated at- 
mosphere on first coming to land in a sickly season. 

As a common rule, regular sufficient diet af- 
fords some protection against the influence of ma- 
laria; and fatigue, low living, debauch, night- 
watching, and irregularity of every kind, favour 
its attack. In temperate climates, where these 
miasmata abound, the practice of over-excitement 
with stimuli will do less harm than in hot 
countries. 

2. Broncliocele. — From the line in Juvenal, 
"Quis tumidum guttur miratur in Alpibusl" it 
would seem that the swelled throat was so com- 
mon a complaint in the Alps in his time, as not 
to excite any wonder. It is still found in the 
valleys of the Alps, and in some other mountain- 
ous countries, as the Pyrenees, the province of 
Behar in India, in Derbyshire, &c. It has been 
observed also in some mountainous parts of Java 
and Sumatra; but it is rare in Scotland ; and Dr. 
Reeve states that it is very common in Norfolk. 
Mungo Park observed the bronchocele in differ- 
ent parts of Bambara, in Africa, along the course 
of the river Niger. Females are far more liable 
to it than males. The opinion that snow-water 
is the cause of this complai'it appears to be quite 
luifounded ; nor can we ascribe it to the use of 
water impregnated with calcareous earth. Yet it is 
probable that air, water, and diet, each contribute 
something towards the cause. Sir S. Raffles tells 



us that there is a village near the foot of the 
Teng'gar mountains in Java, where every family 
is afflicted by this malady ; while in another vil- 
lage, situated at a greater elevation, and through 
which the stream descends that serves for the use 
of both, there exists no such deformity. 

In the pro^^nce of Behar in India, there is a 
district called Tirhoot, (Calcutta Transactions, 
1829, and Edinb. Med. and Surg. Journal, No. 
106), in which bronchocele is common among the 
natives : " and a singular circumstance regarding 
it is, that on a small river of the district it is not 
uncommon to see a village on each bank, and 
quite contiguous, the one with scarcely an indivi- 
dual exempt from the complaint, while in the 
other the inhabitants are perfectly free from it." 

Dr. Johnson cogently remarks, (Med. Chir. 
Rev. vol. vi. p. 422,) " that we obser\'e goitre more 
abundant in some than in other parts of Switzer- 
land, though the diet is the same. In the valley 
of the Rhone we see hardly any thing else than 
cretins and goitres ; while in the valley of Cha- 
mouny, separated only by the Col de Balme, we 
see very few of either disease. We trace bron- 
chocele along the whole course of the Rhine, from 
Schafhausen to Cologne; it gradually decreases 
as we descend the Rhine ; and among those who 
inhabit the banks and drink the waters of the up- 
per or turbid Rhone (in the Vallais) there are 
twenty goitres and cretins for one that can be seen 
on the banks of the lower or filtered Rhone." 
Taken in connexion with the Rhine, it forms (in 
his opinion) a strong ground of presumption in 
favour of the goitrifaciive influence of alpine wa- 
ters. Dr. Johnson, however, does not ascribe all 
the effect to the waters ; and he adds, that " Eng- 
lish children (who live as well as people in 
England) cannot be kept long at Geneva without 
having enlargements of the thyroid gland." He 
concludes, therefore, that the cause cannot be 
traced to sour bread, as Dr. Drug imagined, or to 
any particular article of diet, except water.* 

Notwithstanding the foregoing testimonies, the 
observation of Dr. Mason Good is very important, 
that at Matlock in Derbyshire he found "a large 
number of the poor affected with bronchocele, 
while the rich escaped ; and by far the greater part 
were exposed to all the ordinary evils of poverty. 
(See Study of Med. vol. v. p. 309.) 

Bronchocele has been observed to prevail most 
in situations where humidity is joined with ex- 
cessive heat ; and it is found to increase in spring, 
and to diminish in autumn. Upon the whole, 
a more ample induction is required before the true 
causes of the complaint can be determined : the 
probability seems to be that these are not uniform, 
or, at least, that they are liable to be much varied; 
and that a peculiar combination of air, food, and 
water has much to do in causing the complaint 

* In the work of this able writer and pliilosopliic ob- 
server, lately published, entitled, " Tour of Health, &c." 
hi- says "Ur. B.illy, a native of a goitrous district in 
Switzerland, states the following very important fact. 
BroMchoc.-le appears to me to be produced hy certain 
w^ators winch issue from the hollows of rocks, trickle 
nf7,'f lf.,h '.", '""'""/"■'^. "•■ 'spring from the bowels 
of the earth, that this is the case I m«y instance some 



famil.es in iny own country. Dopartement du I,eman.au 
Ilameau de 1 huct, the use of whose waters will in e/rM 
or Icn days produce or au?menl goitrous swellin"s Such 



of the inhalntants of the above village as avoid those 
waters are free from goitre and cretinism." 



ENDEMIC DISEASES. 



43 



3. Cretinism. — This singular compound of 
mental and physical deformity is found in situa- 
tions, as in the Alps and Pyrenees, not unlike 
those which give rise to bronchocele, with which 
it is sometimes but not always complicated. It 
was first described by Felix Plater in 1635, who 
saw it in Carinthia and the Vallais about the time 
the rickets, with which it seems to be connected, 
was observed in England by Glisson. Cretinism 
was observed by Sir George Staunton in a moun- 
tainous part of Chinese Tartary. (See Good's 
Study of Med. vol. v. p. 334.) A race of cretins 
has also been noticed by Ramond in the south of 
France, where they are widely extended, under 
the name of Cagotts. 

The large deformed head, the low stature, the 
sickly complexion, the vacant and unmeaning 
countenance, the coarse and prominent lips and 
eye-lids, the wrinkled and pendulous skin, the 
loose and flabby muscles, are the physical charac- 
ters belonging to the cretin, which correspond 
with an almost obscured or feebly glimmering in- 
tellect to form one of the most degrading varieties 
of our species. 

According to Saussure, the valleys where cre- 
tinism is most frequent are surrounded by very 
high mountains, sheltered from the currents of air, 
and exposed to the direct, and still more to the 
reflected rays of the sun. The effluvia from the 
marshes are very strong, and the air is humid, 
close, hot, and oppressive. Dr. Reeve, who has 
given a very interesting account of this disease in 
the fifth volume of the Edinb. Med. Journal, says, 
that " all the cretins were in adjoining houses, 
built up under ledges of the rocks, and all of them 
very filthy, very close, very hot, and miserable 
habitations. In villages situated higher up the 
mountains no cretins are to be seen; and the mo- 
ther of one of the children told me, of her own 
accord, that her child was quite a different being 
when he was up the mountain for a few days."* 
It is gratifying to think that the number of cretins 
is diminishing. [Yet, a recent writer, (Twining' s 
Account of Cretinism, Lond. 1843, cited in the 
Br. and For. Med. Rev., April 1844, p. 514) esti- 
mates the number of cretins in Switzerland, who 
are entirely idiotic, to be 8000. The only cause, 
which Dr. Guggenbuhl (Twining, op. cit.) has 
found to be constant in all those localities in 
Switzerland, where cretinism is endemic, is the 
damp warm air of close valleys among the moun- 
tains, where there is no free circulation.] 

It is well observed by Dr. Reeve, that " there is 
no fact in the natural history of man that affords 
an argument so direct and impressive in proof of 
the influence of physical causes on the mind, as 
cretinism. It may be prevented by removing 
children from the confined and dirty places where 

♦ A curious observation is made by Dr. Akerman on 
tliis subject. (See Dr. Tbomas' Practicft, p. 605.) "Those 
who jiiliabit the deepest and most recluse valleys are re- 
duced to the lowest state of imbecility and idiotisni ; in 
those w ho are somewhat more elevated the mental powers 
are not so completely obtunded ; and otiii'rs, still more 
elevated, and of course less exposed to exhalations, will 
probably be ditformed merely with wens or swellings 
about the joints, and other symptoms of rachitis. Those 
who are nearer to the summits are perfectly exempt from 
all these appearances." These facts show a very singu- 
lar correspondence between degrees of elevation in those 
mountainous districts, and a graduated scale of disease 
lessening towards the summits. 



it prevails, and nursing and educating them in the 
higher parts of the mountains." He further states, 
that the disease is looked upon as belonging 
to indigence and poverty ; for, in every place 
where he saw cretins, many well-looking persons 
of both sexes resided, and these were, without 
exception, persons of a higher class in society, 
who lived in better houses, and could supply both 
their moral and physical necessities. 

The production of cretinism by the bad quality 
of the air and food, the neglect of moral education, 
and other evils attendant on poverty, is sufficiently 
proved by the advantages that have attended the 
use of those prophylactic rules laid down by Fo- 
dere, in his interesting and classical work on 
bronchocele and cretinism. And the diminution 
of the number of cretins is ascribed to the drain- 
ing of the fens, the more healthy situation of the 
huts, the clearing of the woods, &c., and, lastly, 
to the progress which has been lately made in 
education among them. (See Medical and Physi- 
cal Journal, vol. v. p. 176.) 

4. Plica, Triclioma, Plaited Hair. — No 
mention is made of this disease either by the an- 
cients or Arabians. Whether it first appeared in 
Poland, in the thirteenth or the sixteenth century, 
is doubled by authors. Pistorius refers to the first 
period, Thuanus to the second. Though plica is 
more frequently observed in Poland and Lithuania 
(and less so than formerly) than in other coun- 
tries, yet it is seen occasionally in Hungary, 
Transylvania, Prussia, Russia, and Great Tartary, 
as well as in Switzerland, Belgium, and some 
parts of France. It is, however, considered to be 
the endemic of Poland. Many marvellous stories 
are current in relation to this disease, not only 
about the causes and contagious nature of it, but 
the danger of attempting a cure. Whatever the 
disease may have been formerly, as to its violence 
and general tendency to supersede other morbid 
affections, in persons constitutionally or heredita- 
rily liable to it, Alibert, De la Fontaines, Baron 
Larrey, and others have lately thrown much light 
upon the complaint, and have proved that inatten- 
tion to cleanliness, and the peculiar habits of the 
Poles, have much to do with the occasional causes. 
Dr. Louis KerckhoflTs (see Med. Trans, of the Col. 
of Phys. Lond. vol. vi.) does not doubt that filth 
is now the cause of it, united to the constant habit 
of the lower classes in Poland of wearing long 
hair, which, in the hottest weather, none of them 
ever clean or comb, and keeping the head always 
covered either with a thick woollen bonnet or a 
leathern cap. To prove that it was not contagious, 
he inoculated himself and two children from the 
fluid filling the bulbs of the hair, which he had 
taken from a hoy labouring under the complaint, 
without any effect. He and the French surgeons 
had no difficulty in curing the disease, in several 
instances, by cutting off the matted and filthy 
hair, and directing the head to be suitably washed. 
It must, however, be acknowledged that in some 
families there seems to be such a predisposition to 
the complaint, that slight causes are sufficient to 
induce it, anil in some cases even strong mental 
emotions have given rise to very sudden attacks 
of it. (See Lorry, de Morb. Cutan.) Dr. Vicat 
(see Edinb. Med. and Phys. Diet. art. Plica\ as- 
signs three causes for this complaint. The first i» 



44 



the nature of the Polish air; the second unwhole- 
some water, for the common people usually drink 
that which is nearest at hand, taken from rivers, 
lakes, and even stagnant pools ; the third cause is 
the gross inattention of the poor to cleanliness, for 
the better class are far less liable to it than those 
of inferior stations ; the inhabitants of large towns 
than those of small villages ; and the free peasants 
than those in a state of vassalage. Dr. KerckhofTs 
confirms the fact that the rich are generally ex- 
empt from plica, and that it is seldom seen but 
among the poor, " who wallow in filth and mi- 
sery" — (qui croupissent dans la misere.) 

5. Guinea-Worm. — Plutarch, (Sympos. 
cap. ix.) slates that those who live near the 
Red Sea are liable to a disease in which small 
worms, called dracontia, are found in various 
parts of the body. Kcmpfer observed the disease 
in the island of Ormuz, in the Persian Gulph, 
and also in Tartary. According to Wclsch, it is 
known to prevail among the negroes in all the 
marshy parts of Africa. The worm is a native 
of both Indies. Dr. Chisholm, who has given 
the fullest and best account of the dracunculus 
that we have seen, (Edinb. Med. and Surg. Jour- 
nal, vol. ii. p. 145,) says that the complaint is not 
confined to the natives of Africa in the West In- 
dies, and that it is an endemic, and, during a cer- 
tain portion of the year, an epidemic disease, in 
the island of Grenada, where he practised. In 
one estate of this island all the field-negroes, about 
three hundred, who drank of a particular well, 
had the disease every year, in the months of No- 
vember, December, January, and February, for 
several years, (or from the year 1787, when the 
well was dug, till 1794, when Dr. Chisholm left 
Grenada ;) and from March to November not an 
instance of the disease occurred among them. In 
another plantation the same thing was observed, 
and after cisterns were made to hold rain-water 
for common drink, and the wells were filled up, 
the disease entirely disappeared. The domestic 
negroes and whites who drank roiVi-water, while 
the well-waier was in use, generally escaped. 
Three infants, from five to seven months' old, to 
whom their mothers had incautiously given the 
water of the well, had each a worm in one of 
their legs ; and a domestic negro boy, who in the 
year 1793 drank of the well-water, had several 
Guinea-worms the same year, a7id only thai year. 
In a third jdantation similar facts were noticed ; 
none of the whites on the estate had the disease 
except one, who inconsiderately or ignorantly 
drank of the well-water. 

Bruce and Mungo Park give a similar testimo- 
ny respecting the effects of particular wells in 
Africa ; and Dr. Chisholm concludes that " in all 
countries in which the dracunculus is endemic, 
the prevailing belief of the people is, that it pro- 
ceeds from drinking water which contains the ova 
i>r the embryo of the animal." 

It is a singular fact that the disease is observed 
10 prevail at Bombay and along that part of the 
(.oast of India about the same time of the year 
when it prevails in the West Indies, viz., in the 
months of December, January, and February. It 
also appears in many other districts in the Car- 
natic and Madura, to within the distance of one 
»r two days' journey from the sea-coast. A learn- 



ENDEMIC DISEASES. 

ed missionary, named Dubois, in a letter to Dr. 
Anderson, the physician general, states tliat lie 
has often seen villages in which more than half 
the inhabitants were affbctcd by it at the same 
time. The inhabitants of a village who dnnk 
water from one well are attacked by the disease 
while the inhabitants at the distance ol only half 
a mile who drink water from another well are not 
affected by it. Besides, the inhabitants living on 
the shore of the Cavary and other rivers, who 
constantly drink their limpid waters, are never 
visited by it ; while those who live at the distance 
of one mile on both sides, and are obliged to drink 
the saltish water of wells, are all, or the most part, 
yearly exposed to it. 

Dr. Smyttam (Calcutta Med. Trans, vol. i.) 
confirms the observation of Dr. Chisholm and 
others that " an argillaceous (^and tuffy') soil, with 
a considerable impregnation of salt, or percolated 
by sea-water, is what the Guinea-worm affects." 
And another fact seems to be pretty well ascer- 
tained, both in the East and West Indies, that 
the worm not only insinuates itself into the body 
through the skin, but that its ova may be convey- 
ed into the system through the stomach, and de- 
posited in the cellular membrane under the skin, 
where it attains its growth, and at length pro- 
duces that local irritation which leads to its ex- 
pulsion. 

The fact that those who are affected with the 
dracunculus rarely suffer from any other disease 
at the same time, with a few other reasons which 
appear entitled to little weight, has led some per- • 
sons, and lately Dr. Milne of Bombay, (Edinb. 
Med. and Surg. Journal, No. 106,) to maintain 
the position that the substance which is observed 
in this disease " is not a worm, but a lymphatic 
vessel." We cannot take further notice of this 
opinion, nor is it necessary to advert to the cir- 
cumstances which led Sir James Macgrigor to 
conclude that the dracunculus was contagious, as 
the facts have been explained by Dr. Chisholm on 
a far more reasonable hypothesis. 

The Guinea-worm has been rarel)' seen in its 
native state out of the body. Nevertheless, the 
observations of Dr. Helenus Scott of Bombay, 
(See Medico-Chir. Review, vol. iv. 1823,) and 
recently those of Dr. Robert Grant, (Edinb. Med. 
and Surg. Journal, No. 106.) set the question of 
its independent existence at rest. 

6. Blostalgla.* — The concourse of depressing 
symptoms which sometimes arise in persons who 
are absent from their native country, when they 
are seized with a longing desire of returning to 
their home and friends and the scenes of their 
youth, constitutes the disease called nostalgia. 
Some have considered it peculiar to the natives 
of Switzerland, because it was often observed in 
the Swiss soldiers when on foreign service. But, 
alas ! too many instances of this affection occur 
in the natives of other countries, and evince that 
it has its source in the very frame and constitu- 
tion of human nature in every part of the world. 
Though It might appear that the inhabitants of 
mountainous countries were more liable to nos- 
talgia than others, yet many instances have oc- 
curred in which a removal from the plain to the 



[* It is not easy to see how Dr. Hancock makes thi. 
an endemic disease.] "HKes trug 



ENDEMIC DISEASES, 



45 



mountain has produced this melancholy. It 
would seem as if no country were too wild and sav- 
age, if but the simplest means of supporting hu- 
man life were at hand, not to attach the natives 
to it. Our affections, like the tendrils of the vine, 
adhere to the objects that are first presented to 
them, whether animated or inanimate, with so 
firm an embrace that nothing but violence can 
break the connection. 

Every one accustomed to the variety and beau- 
ty of mountain scenery, and capable of feeling in- 
tensely the delights of rural manners, can conceive 
without difficulty the anguish and shock to the 
physical powers, which is often sustained by those 
who are thus ardently devoted to their friends and 
native country, when they have been rudely sepa- 
rated from them.* The Laplander feels the most 
enervating and listless despondency, when absent 
from his snowy mountains and frozen lakes. The 
North-American Indian sighs amidst the festivi- 
ties and comforts of polished life for the earthy 
couch in his native wilds, and the free range of 
his interminable forests. And the poor negro, 
even if cruel bondage were not his portion, might 
be expected to utter bitter complaints for the loss 
of family endearments and of the noontide repose 
in the sultry retreats of African luxuriance. Many 
of the ill-fated Africans, it is well known, perish 
from suicide and dirt-eating in those polluted and 
polluting islands, where we cannot say that 

"No fiends torment nor Christians thirst for gold." 
Even the hardy and almost unyielding nature of 
the British seaman, when he has just set foot on 
his native land after a long voyage, and been 
pressed against his will to leave once more the 
objects dearest to him in life, has often been sub- 
dued by this powerful influence so completely as 
to he quite disqualified for the duties to which he 
was called. Within the last forty years, perhaps 
no country in Europe has afforded so many in- 
stances of the overwhelming influence of the dis- 
ease in question as France, notwithstanding the 
natural buoyancy of spirit and thirst after military 
glory for which that nation is distinguished. 
There was scarcely an encampment during the 
war in which the skill of the medical attendants 
was not called forth, assiduously and painfully, to 
counteract the pernicious effects of nostalgia, — 
pernicious, and, indeed, often fatal in a high 
degree, when any other debilitating or depressing 
powers were apphed at the same time, and acting 
together with this epidemic melancholy upon the 
young soldier. It was then observed that a slight 
wound, d3^sentery, fever, extra fatigue, or a disas- 
trous engagement, hurried multitudes into a state 
of mortal depression. (See Percy and Laurent, 
Diet, de Sc. Med. art. Nostalgic.) 

7, Taraiitismus. — A disease was formerly 
supposed to be epidemic in Apulia, and only in 
that part of Naples, which was so called from the 
spider named aranea tarantula, whose bite was 
said to be the cause of it. The peculiarity of the 
disease mainly consisted in the uncontrollable pro- 



*The celebrated Swiss air called Rans rtcs Vaches, 
imitating the full rebounding echo of the Alpine herd 
amongst the mountains, might well awaken mournful 
recollections in the bosom of the absent soldier, so as to 
require tharthe plaving of it should be prohibited under 
a severe penalty 



pensity of the sufferer to dance in the most violent 
manner at the sound of certain music — some 
affected by one sort and some by another — till 
copious perspiration and excessive fatigue put an 
end to the disease, and thus destroj-ed the effects 
of the poison. This was the common opinion, 
and men of science received it as agreeing with 
matter of fact. Tarantismus affords one of those 
humiliating lessons which may too frequently be 
drawn from medical records, on the diliiculty of 
ascertaining facts, and the prevalence of unfound- 
ed opinions, even among distinguished physicians. 
Kircher, Sir Thomas Browne, Baglivi, Boyle, 
and Mead, have not hesitated to give credit and 
countenance to the statements relative to the 
wonderful effects both of the bite of the tarantula 
spider upon the body, and of the music as a re- 
medy. Yet it would appear that they were all 
misled by a popular error. The treatise on the 
tarantula of a physician so eminent as Baglivi, 
who was himself an Apulian, tended to confirm 
the delusion. 

On the contrary side of the question we have 
the strong testimony of Dr. CorneHo, a Neapoli- 
tan physician, so far back as 1672, of Dr. Serao, 
an Italian, and of Dr. Cirillo, professor of natural 
history in the university of Naples, so lately as 
1770, besides that of many others since that time. 
(See Phil. Trans, for 1672 and 1770.) Cornelio 
says that " all those that think themselves bitten 
by tarantulas, except such as for evil ends feign 
themselves to be so, are mostly young wanton 
girls, who persuade themselves they have been 
stung by a' tarantula, according to vulgar preju- 
dice, in consequence of having fallen by some 
particular indisposition into this melancholy mad- 
ness." Dr. Serao has written an ingenious book, 
in which he has effectually exploded this opinion 
as a popular error. Dr. Cirillo asserts that, " hav- 
ing had an opportunity of examining the effects 
of this animal in the province of Taranto, where 
it is found in great abundance, he finds that the 
surprising cure of the bite of it by music has not 
the least truth in it. In Sicily, where the summer 
is still warmer than in any part of Naples, and in 
Tunis also, where this spider is found, the taran. 
tula is never dangerous, and music is never em- 
ployed for the cure of the pretended tarantism. 
(See Edinb. Med. and Phys. Diet. art. ArancaA 

Dr. Laurent, who lived in the kingdom of Na- 
ples for a long time as chief surgeon to the French 
army, says that the bite of the tarantula does 
really cause a slight inflammation, but that taran- 
tism, as described by authors, no longer exists. 
He has often seen, at Naples, ten or a dozen young 
girls running about the streets, each having a 
small tambour, and performing with a kind of 
violent effort, accompanied by the most wanton 
gestures, the dance thej call tarantella, a national 
dance from time immemorial known in that coun- 
try. Hence, Merat thinks it is probable that taraw 
tismus, the disease, is nothing but tarantella, the 
dance, adorned with some fables. Nollet, an 
eminent physician, was satisfied, when in Italy, 
that the vulgar notion was unfounded ; that, 
even in Apulia, sensible people gave no credit to 
it ; and that it was only some of the very lowest 
class, who, pretending that they were bitten, ap 
peared to be cured by dancing and music in 



46 



ENDEMIC DISEASES-ENTERITIS. 



order that they might gain a subsistence by this 
kind of imposture. We are assured that the 
opinion of all the physicians of the country is that 
the bite is liarmless, if not aggravated by impro- 
per applications ; and that they consider the pre- 
tended tarantism arising from it as visionary. 
Baglivi himself admits that "that spider is only 
venomous in the dog-days, and in very hot situa- 
tions, for, at other times, and in the mountains, 
and in other countries, it is not so." Tliis is a 
remarkable concession. 

The fact is, that the inhabitants of Apulia, 
breathing a hot and dry air, are liable to inflam- 
mations of the head and chest, and to spasmodic 
affections ; and sufficient grounds appear for con- 
sidering the aggregate of symptoms, called taran- 
tismus, as a nervous complaint, incident to a peo- 
ple naturally choleric, ardent, impatient, liable to 
insanity, fond of a dance of which violent gestures 
constitute a peculiarity, and easily affected by 
music. (Diet, des Sciences Med. art. Tarantisme.') 
Besides the diseases above noticed, some others 
are classed with endemics, as beriberi, attributed 
to the alternation of extreme heat in the day with 
cold and damp in the night ; ophthalmia, in 
Egypt, to solar heat and an adust air imbued with 
impalpable sand ; elephantiasis, in the same coun- 
try, to corrupt water and the use of salt indigesti- 
ble food amongst the poor, added to the filth in 
houses and persons ; pellagra, in Milan, and a 
species of lepra, in Asturia, to bad food and sordid 
habits also ; framboesia, or yaws, in Africa, and 
among the negroes in the West Indies ; tetanus 
and trismus in tropical climates, east and west; 
the Barbadoes, or Cochin leg, &c., to causes not 
well ascertained. Respecting each of these some 
interesting facts might be stated ; but we have only 
room for a few general observations. 

In the first place, we may remark that abject 
poverty is the soil in which most endemic diseases 
spring up in every country. Upon the poor, ill- 
fed, harassed population, living in closeness and 
filth, these diseases commonly fall, while those 
who live well and are but little exposed to the in- 
jurious qualities of air, soil, and water, are in 
great measure exempt. Secondly, if we may form 
any just idea of the causes of physical evils in 
general, from a consideration of the means which 
have been found useful in preventing them, then 
it is clear that, although some complex appear- 
ances and seemingly contradictory facts enter into 
the catalogue of assigned causes of man)' endemic 
diseases, so far as they appear to depend on air, 
soil, food, and drink ; yet, on the other hand, pro- 
per attention to these things is found, in almost 
every instance, to be effectual in suspending and 
finally removing the maladies in question. Bv 
draining marshes and cultivating lands, by pro- 
viding plain sufficient food and wholesome water, 
with airy dwellings for the poor, it cannot be 
doubted that a host of physical evils would be 
avoided. Thirdly, had we time to pursue this 
subject further, there is wide scope for reflection 
on the duties which devolve upon the rich in 
every country to relieve the necessary wants and 
sufferings of their poor neighbours ; on the provi- 
»ion which is made in the nature of things, by a 
aiyiintiful Creator, for the relief of human misery. 



in every climate and in all situations in life, if 
man himself, or at least those who are in power 
would but apply the means— if luxury would 
make a small sacrifice of self-indulgence to the 
public good; and, lastly, on the physical blessmgs 
that would result from this wise paternal care, not 
only comforting and rejoicing the poor objects 
themselves, but enriching their benefijctors, caus- 
ing the face of nature to smile around them, and 
giving them the never-failing reward of sound 
policy and of Christian benevolence. 

T. Hancock. 

ENTERALGIA. (See Colic.) 

ENTERITIS. This term has been long used 
in medicine to express an inflammatory state of 
the intestines, but it is only within our own time 
that pathologists have attached any definite mean- 
ing to the expression. In the other books we 
read of gastritis, peritonitis, and enteritis, of 
which latter Cullen describes two species, the 
phlegmonous and erythematic ; and it is remark- 
able that by a species of consent among medical 
men the term has been chiefly used to express the 
first of these species, or the acute inflammation of 
most if not all the coats of the intestine. But 
modern researches have greatly extended our views 
of enteritis, although the true pathology of the in- 
testine is not yet sufficiently recognised by most 
practitioners. 

Enteritis is now known as a disease perhaps 
the most protean of any of the affections of the 
body ; occurring with every variety of intensity, 
from a slight and circumscribed vascularity to the 
most extensive disorganization ; simulating by its 
numerous sympathetic irritations many of the dis- 
eases of the nervous, respiratory, circulating and 
genito-urinary systems ; accompanied by the most 
violent symptoms of irritation, or only pointed out 
by a profound adynamia ; or, lastly, advancing 
with perfect latency to incurable disorganization. 
A formidable disease in its idiopathic form, its 
supervention in the course of other affections is a 
matter of daily occurrence, and in one particu- 
larly, (fever,) a common cause of its fatal termina- 
tion. We shall dwell on this part of the subject 
hereafter, and endeavour to show that the enteritis 
of typhous fever is more a consequence than a 
cause of the disease, but still not the less import- 
ant in its prognosis and treatment. Compared 
with other affections, both acute and chronic, the 
frequency of intestinal disease must strike every 
observer. Andral, who, from his vast experience, 
and the fact of his having no theory to defend, is 
the best authority on this subject, declares that in 
the great majority of acute diseases of other parts, 
a derangement either in the functions or structure 
of the intestinal canal will occur; and that in 
chronic diseases, whatever be their nature, it is 
extremely rare that the digestive tube escapes 
alteration. These complications of course forh. 
part of our subject, but here we shall merely 
remark that it is difficult to estimate the benefit 
which Broussais has conferred on medicine by 
calling the attention of pathologists to the fre- 
quency and importance of irritations of the diges- 
tive system; and if, in the ardour of discovery 
this great physician has in one instance passed 



ENTERITIS, 



47 



the bounds of strict induction, the error is more 
than atoned for by the extensive good of which 
he is the undisputed author. 

We shall here treat of the different inflamma- 
tory affections of the intestinal canal, from the 
pyloric end of the duodenum to the rectum, 
reserving the consideration of gastritis and perito- 
nitis for separate articles. 

We recognise inflammatory affections of the 
digestive tube by the alterations of function, the 
local phenomena and the sympathetic irritations 
which occur. The general symptoms may be 
enumerated as follows : indigestion, anorexia, 
vomiting, thirst, jaundice, tympanitis, constipa- 
tion, alteration of the faecal discharges in quality 
or quantity ; pain, tenderness on pressure, c(m- 
traction of the features, morbid state of the 
tongue, dryness of the skin, and conjunctiva ; 
suppression of urine, sighing, stupor, delirium, 
headach, prostration, accelerated and thoracic 
respiration, fever. 

We shall find that the greatest variety in the 
combinations of thesp symptoms may occur, prin- 
cipally arising from the following circumstances : 
— the intensity and extent of the inflammation ; — 
the situation of the disease, both as to the differ- 
ent parts and tissues of the tube ; — the complica- 
tions with other diseases ; — the different degree of 
excitability of the nervous system in different 
individuals. Thus, when the inflammation is 
extensive and severe, occupying both the stomach 
and intestines, we may have the worst forms of 
bilious or gastric fevers ; when it occupies the 
duodenum, jaundice is a common symptom, and 
the disease may occur with or without fever: in 
the small intestine a slight inflammation is often 
nearly latent, or only pointed out by a little swell- 
ing or pain, while in the ca}cum or colon the dis- 
ease produces all the varieties of diarrhoea and 
dysentery. When the upper portion of the tube 
is engaged, constipation is a common symptom ; 
w^hen the lower, the reverse takes place. If the 
mucous membrane alone is engaged, pain and 
costiveness are ■often absent ; but when all the 
coats are in a state of acute irritation, we may 
find the most violent symptoms of peritonitis and 
ileus, with contractions, intus-susceptions, &c. 
The complication of the disease with other affec- 
tions also produces great varieties. Thus when it 
occurs in the advanced stages of phthisis, diarrhoea 
is often the only symptom ; or when complicated 
with erysipelas or pneumonia, its most prominent 
indication is an extraordinary prostration. The 
different degrees of excitability of the nervous 
system cause the greatest irregularity of symptoms: 
in the child, acute enteritis is commonly mistaken 
for inflammation of the brain ; in the adult a cir- 
cumscribed irritation will in one case be accom- 
panied by violent delirium, while in another, more 
severe, this symptom shall be completely absent. 

We have already spoken of the great frequency 
of abdominal irritations occurring alone, or in 
combination with other affections. This know- 
ledge is the discovery of our own time, and may 
be looked on as the greatest improvement in 
modern pathology. The humoral school could 
see in most digestive derangements nothing but 
the accumulation of sordes : and hence the emetic 
and purgative practice, in cases where a decided 



inflammation existed in some part of the tube. 
They never thought of treating inflammatory dis- 
eases of the abdomen as such, unless when they 
occurred in the highest degree of intensity, in- 
volving all the coats of the intestine ; and of the 
nature and symptoms of irritations affecting the 
mucous system they were almost wholly ignorant. 
The followers of Brown, on the other hand, saw 
in these affections only debility, because most of 
them are accompanied by prostration of strength, 
functional injviry, a weak pulse, and in some cases 
by completely typhoid symptoms. Ignorant of the 
fundamental law of pathology, that local excitation 
or inflammation may coincide with a diminution 
of the general vita! force, they prescribed stimu- 
lants, which only increased the debilitj' by exas- 
perating its cause. The progress of medicine has 
shown, that to various modes and shades of irrita- 
tion of the gastro-intestinal surface, a great num- 
ber of affections, the nature of whidh was pre- 
viously obscure, are to be referred. We now 
know that many cases of what has been called 
idiopathic fever are of this nature, and that it is a 
common source of dyspepsia, hypochondriasis, 
jaundice, hepatic obstructions, and t^'mpanitis ; 
that diarrhoea and dysentery constantly arise from 
it ; and that in very many cases ileus, conslipa- 
tion, infantile remittent, tabes mesenterica, melaj- 
na, and hemorrhage from the bowels, are results 
of this morbid state. To this cause also may be 
traced many of the irritations of other systems : 
it may produce hysteria, epilepsy, tetanus, mania, 
cough, and accelerated breathing, palpitation, sup- 
pression of urine, dropsy, rheumatism, and disease 
of the skin. 

We shall endeavour to study the history and 
symptoms of enteritis separately from those of 
gastritis, as far as this is possible ; for in manj 
cases the coincidence of the two affections pie- 
vents this analysis. We shall examine first, the 

Acute and Chuonic Ej^teritis of the Ii'j- 
FAXT ; and, secondly, these affections in the adult. 
Enteritis may be an intra-uterine disease ; and it 
appears probable that many of those infants who 
continue in a state of debility and marasmus frojji 
birth, have really been born with this affection. 
In some infants who have died but a few days 
after birth, unequivocal marks of chronic inflam- 
mation of the intestine have been found ; and in 
others who have lived but two days, the various 
appearances of more acute irritation have been 
observed. These facts render it probable that the 
delicacy of infants may often be ow-ing to this 
cause, and should render practitioners much more 
cautious in the use of the tonic, stimulant, and 
purgative treatment. 

During the period of lactation, infants are ex- 
tremely subject to inflammation of the mucous 
membrane of the intestines — a circumstance at- 
tributable to the high degree of susceptibility which 
the tube is endowed with, and the great activity 
of the digestive function ; and in most countries 
also, the irregularities of diet, and the frequent 
use of stimulants and purgatives powerfully aid ii. 
producing this result. 

Enteritis may occur in the infant under two 
principal forms : in the first there is absence oi 
fever, and frequently of the other sympathetic 
irritations, the symptoms being merely local : 3i> 



43 



ENTERITIS, 



the second we have the local symptoms, but with 
fever and signs of irritation in the nervous and 
respiratory systems. The first form is that to 
which the youngest infants arc most subject, the 
second being more liable to occur as the child ad- 
vances in age. As in the adult, the symptoms 
vary with the portion of the tube attected, and in 
the youngest children they are most commonly 
those of gastritis and enteritis. Vomiting, diar- 
rhoea, tympanitic swellings and pain on pressure 
are the most common symptoms of this disease. 
The tongue is most generally dry, furred, and red 
at the tip, and the skin dry ; and when diarrhoea 
exists, an erythematous redness round the anus 
has been observed. Fever may or may not be 
present, and it often happens that the abdomen 
feels preternaturally hot. Towards the fatal ter- 
mination of the disease the skin becomes cold, 
wrinkled, rough, and of a dirty appearance ; the 
emaciation is extreme, and the muscles are soft 
and flabby. The character of the face is remark- 
able ; the hollow cheeks, corrugated forehead, 
and retracted mouth, giving to the child a melan- 
choly and singular expression of age and suf- 
fering. 

Dr. Abercrombie describes this disease in chil- 
dien of from six to eight months old, and states 
that in its early stages it is difficult to distinguish 
it from the ordinary bowel complaints of children 
at the period of dentition. He relies principally 
on the occurrence of fever, but we have seen that 
in the very young child this is insufiScient, the 
symptoms being merely local. The following is 
his account of the symptoms: — " The infant is 
usually hot and restless in the early stages, with 
thirst ; and the tongue is dry, or covered with a 
brownish crust ; there is in general a good deal 
of screaming and fretfulness, disturbed sleep, fre- 
quently vomiting, and in many instances pressure 
on the abdomen appears to give uneasiness. The 
bowels are loose, but this is not in every case a 
prominent symptom, for even in the advanced 
stages the bowels may not be moved above three 
or four times in the twenty-four hours, while the 
disease is advancing rapidly to a fatal termination. 
In other cases, however, this symptom is more 
urgent, the evacuations being preceded by much 
restlessness and appearance of pain, and the mat- 
ters evacuated are sometimes discharged with a 
remarkable degree of force, so as to be propelled 
to a considerable distance. The evacuations vary 
considerably in appearance, and I have never been 
able to satisfy myself that any reliance is to be 
placed upon them in ascertaining the disease. 
They sometimes consist chiefly of a reddish- 
brown mucus, sometimes of a pale claj^-coloured 
matter, and sometimes of a dark watery fluid ; 
but in many cases they show little deviation from 
the healthy state, while in others their appearance 
is evidently disguised or modified by articles of 
nourishment, which pass through nearly un- 
changed. The disease often goes on for some 
tim.e without exciting alarm or being distinguished 
from an ordinary diarrhcea, until attention is sud- 
denly directed to it by the occurrence of consti- 
(iitional symptoms. These consist in some cases 
of a great degree of febrile oppression, with dry 
frusted tongue, thirst, and vomiting; in others, 
iif a verv sudden and rapid exhaustion of the vital 



powers, which is unexpected, and not accounted 
for by the frequency of the evacuations; and 
sometimes the first appearance of unfavourable 
symptoms consists in the occurrence of coma, 
with a pccuUar hollow languid look of the eye, 
and a pale waxen aspect of the whole body, while 
the pulse perhaps continues of tolerable strenf^th. 
These symptoms may appear while the disease has 
been going on but for a short time, and while the 
evacuations have been by no means frequent; 
while the aflection, in short, had not been distin- 
guished from the ordinary bowel complaints of 
infants." (On Diseases of the Stomach, &c.) 

Billard has observed out of eighty cases of in- 
flammation of the intestinal tube in infants at the 
breast, thirty of inflammation of the small intes- 
tine and colon ; thirty-six of the disease in the 
small intestine alone ; and fourteen cases of in- 
flammation of the colon. In twenty of the first 
set there was bilious diarrhcea, and in all swelling 
and tenderness of the belly : in twelve cases 
bilious vomiting took place, although there was 
no gastritis: in all, the erythematous redness 
around the anus occurred ; the tongue was in 
most cases red and dry, and the skin very hot and 
arid ; but the pulse was rarely excited to any fe- 
brile degree, and was frequently feeble. In the 
thirty-six cases where the small intestine was 
alone engaged, there were instances of vomiting 
in twenty ; and in fifteen of these latter the dis- 
ease was situated in the ileo-caecal region and 
valve. The belly was in all, at some period of 
the afl!ection, tympanitic. In twenty-five there 
was purging of a yellowish matter, and of a »ub- 
stance resembling meconium ; the tongue was al- 
most always red, the skin hot, but the pulse httle 
excited. In these cases also the erythema around 
the anus was generally observed. The fourteen 
cases of inflammation of the colon were all ac- 
companied with diarrhoea, the tympanitis was 
much more slight, and in six of the cases only 
did vomiting take place. There was commonly 
great agitation, and a remarkable dryness of the 
skin, which was generally cold and Uvid. The 
pulse was scarcely excited. (Traite des Maladies 
des Enfans.) 

From these important observations it would 
appear that the tympanitis, vomiting, and diar- 
rhcea are the principal signs of the inflammation 
of the mucous membrane of the small intestine, 
while in the simple colitis it is most commonly 
mdicated by a diarrhoea, attended with but little 
swelling of the belly. 

The absence of excitement of the pulse in these 
cases IS a point of great practical importance, 
showmg how guarded we should be in any case 
of intestmal disturbance during the period of lac- 
tation. This proposition then appears fully esta- 
blished, that in the infant at the breast fatal ente- 
ritis may occur without fever, and commonly with- 
out excitement of the pulse. 

We must never lose sight of tliis fundamental 
principle of diagnosis as applied in particular to 
the enteritis of children, that no one sy„>ptom is 

:tZl I'Zr ^^-'^"---^V/* absolute 
certainty. A child may have vomiting alone or 
diarrhcea alone, or colicky pains without enter itS 
The occurrence of any one of these with fever J 
indeed a nearly unequivocal indication of inflar; 



ENTERITIS. 



49 



mation ; but, as we have seen, fever may be ab- 
sent, and then, as to diagnosis and practice, it is 
to the group of phenomena that our attention is to 
be directed. And it should further be borne in 
mind that aUhough the symptoms of vomiting, 
diarrhoea, and pain, taken singly, sometimes can- 
not be connected with a state of inflammation, 
yet that in most cases they are really owing, if 
not to this condition, at least to an excited degree 
of action and irritability which demands the same 
principles of treatment. 

The sympathetic irritations which are most 
prominent in cases of the enteritis of children, are 
those of the respiratory and nervous systems. It 
is of the greatest importance that these should be 
well understood. It appears that although at first 
they are not necessarily accompanied by organic 
changes in the parts, )'et that in most cases these 
will sooner or later occur, and an organ, at first 
only sympathetically irritated, become at last really 
inflamed. We may then have a true revulsion 
of disease, or, what is more common, a new visce- 
ral inflaiv nation, in combination with the original 
disease. The child may then have bronchitis or 
pneumonia, or arachnitis, or encephalitis, together 
with the primary enteritis. 

We have often seen children who were sup- 
posed to be labouring under severe pneumonia, 
from the great acceleration of breathing and fever, 
yet on examination by percussion and the stetho- 
scope have found either that no disease existed in 
tiie chest, or that there was a slight bronchitis, not 
suflScient to account for the symptoms. In most 
of these cases the patients had been treated for 
pulmonary inflammation, and without success ; 
and with scarcely an exception the symptoms have 
yielded to the application of leeches to the belly, 
the use of cold drinks, and the avoiding every 
thing calculated to irritate the gastro-inlestinal 
surface. 

Tlie symptoms of cerebral irritation are more 
common as a result of enteritis in the child than 
in the adult. We may observe all the ordinary 
signs of acute inflammation of the brain, such as 
pain, delirium, coma, &c., and yet on dissection, 
this organ be found without appreciable lesion, but 
the digestive tube highly inflamed ; and it is the 
opinion of some of the best pathologists, that in 
the infant the most common cause of hydrocepha- 
lus is a primary irritation of the digestive tube. 
On the other hand, we know that symptoms of 
abdominal disease will arise from an encephalitis; 
but of the two cases, the former appears to be the 
more frequent. 

There are three affections to which children are 
extremely liable, the essence of which appears to 
consist in an inflammatory state of the digestive 
tube ; these are the weaning brash, the infantile 
remittent, and tabes mesenterica. It is now satis- 
factorily proved that a diseased state of the mu- 
cous membrane is the principal pathological phe- 
nomenon in these affections. The study of the 
symptoms, the history of the exciting causes, and 
the appearances on dissection, all go to establish 
this doctrine, which is not new, but by no means 
sufficiently recognised by medical men. The first 
of these is manifestly an acute enteritis, produced 
iiy the change of food, and in which nature seeks 
to relieve the inflammation by a super-secretion ; 

Vol. II. — 7 e 



and hence the danger of the too sudden suppres- 
sion of the evacuations, which lights up fever, and 
is commonly followed by cerebral symptoms. The 
phenomena of the second are all referable to a less 
violent irritation, but one which, if not relieved in 
time, will destroy life with the symptoms of tabes 
mesenterica, or if exasperated by improper treat- 
ment, may run the usual course of more violent 
inflammation. It may be objected to this view 
of the disease, that it is often relieved by the pur- 
gative plan ; but the reverse often occurs, and we 
constantly meet cases of tabes mesenterica, where 
the first symptoms were those of the infantile re- 
mittent, and in which this mode of treatment has 
altogether failed. This apparent paradox admits 
of explanation : where the first symptoms come 
on in children who have been over-fed, or have 
used highly indigestible articles of diet, the use 
of purgatives in the early stages may and does 
effect a cure by the evacuation of the noxious 
substances ; but there is a period beyond which 
this treatment cannot be pushed with safety, and 
if the symptoms do not yield to the use of laxa- 
tives, different means must be adopted. These 
are means calculated to relieve inflammatory ac- 
tion in the mucous membrane, a state, the exist- 
ence of which is proved by the appearances on 
dissection, which include all the effects of inflam- 
mation on the digestive tube. 

The pathology of tabes mesenterica is not yet 
completely cleared up ; but the following circum- 
stances are almost decisive in favour of the opinion 
that it arises in most cases from chronic enteritis. 

First. The mesenteric glands may become en- 
larged, inflamed, and suppurated in cases of acute 
and chronic enteritis both in the infant and the 
adult. Secondbj. The great majority of cases of 
this affection have commenced with symptoms of 
enteritis. Thirdly. The dissections of most cases 
have shown an inflamed and ulcerated state of the 
mucous membrane. Fourthly. The treatment 
which is found most efficacious is that calculated 
to remove this condition of the intestine. 

It is true that a few cases are to be met with 
where the enlarged and tubercular state of the 
mesenteric glands cannot with certainty be traced 
to enteritis ; where in fact the mucous membrane 
does not present any trace of disease. These ap- 
pear to be examples of a general disposition to 
tubercular degeneration of the glandular system, 
and are exceedingly rare as compared with the 
others. The absence of vascularity in the mucous 
membrane may in some instances arise from revul- 
sion, such as would occur from u new and violent 
inflammation of some other organ ; and we have 
seen cases where it would be attributed to mere 
anaemia, from the extreme emaciation of the pa- 
tient. This pathology of tabes mesenterica was 
first developed by Broussais, in his Examen dcs 
Doctrines Medicales, in the year 1816, where he 
declares that the tumefaction of the mesenteric 
glands arises from enteritis, in the same manner 
as bubo in the groin arises from chancre. In this 
disease the fever was attributed to the engorge- 
ment of the mesentery, when in fact both of these 
were secondary phenomena ; the true cause was ■ 
not understood, and hence the uncertain and erro 
neous treatment of the affection. 

As we should expect, this result of enteritis n 



50 



ENTERITIS. 



much more common in subjects of the strumous 
constitution, or, in other words, in those where the 
lymphatic system is predominant. Hence the 
reason of its greater frequency in children, and, 
when occurring in the adult, in the scrofulous 
constitution. 

Two important facts are stated by the above 
author in reference to tabes mesenterica ; one, that 
it has been observed to be more frequent during 
moist seasons; the other, that simple peritonitis 
will not produce the disease. 

[The inflammation of the lining membrane of 
the intestines of the infant, may vary in character, 
like that of other mucous membranes, and be ery- 
thematous, pseudo-membranous and ulcerated, or 
follicular. The inflammation of the patches of 
Peyer is often identical, except in intensity, with 
that of the typhoid affection. The appearance 
is the same; and, according to MM. Barthez & 
Rilliet, (Trait e C Unique et Pratique des Mala- 
dies des Enfants, i. 482, Paris, ] 843,) " if there 
be a difference between the two diseases, it must 
be sought for elsewhere than in the lesion of the 
patches (plaques.)" These gentlemen maintain, 
indeed, that there are many relations between ty- 
phoid fever and enteritis in the infant. The fol- 
lowing table is given by them to exhibit the man- 
ner in which the different intestinal lesions are 
combined ; and to prove from the diversity of the 
combinations, that it is useless to endeavour to esta- 
blish the symptomatology of each anatomical form : 

Enteritis (erythematous, pseudo-niemhranous ulcera- 
ted or pustular, 45 

Colitis, (of the same nature), 113 

Follicular enteritis, 90 

Follicular colitis, 04 

Softening of the small intestine, 28 

Softening of the large intestine, 35 

These lesions were associated in the same indi- 
vidual, so as to form the following combinations ; 
1 85 being the number of necroscopies : 

Enteritis alone, 2 

Colitis alone, 32 

Entero-colitis alone 11 

Follicular enteritis alone, 12 

Follicular colitis alone, 3 

Follicular entero-colitis alone, 10 

Enteritis and follicular enteritis, 8 

Colitis and follicular colitis, 12 

Enteritis and follicular entero-colitis, 2 

Colitis and follicular enteritis, 17 

Colitis and follicular entero-colitis, 11 

Entero-colitis and follicular enteritis, 7 

Entero-colitis and follicular colitis, 9 

Entero-colitis and follicular entero-colitis, 7 

Softening of the great intestine, 8 

Softening of the small and great intestine, 10 

Enteritis and softening of the great intestine, 1 

Colitis and softening of the ^nuill intestine, 2 

Colitis and softening of th.; great intestine, ] 

Enteritis, colitis and softening of the great intestine, 2 
Softeningof the small intestine and follicular enteritis, 1 
Softening of the great intestine and follicular colitis, 1 
Softening of the small intestine and follicular colitis, 1 
Softening of the small intestine and follicular entero- 
colitis, ] 

Softening of the great intestine and follicular enteritis, 3 
Softeningof the large intestine and follicular entero- 
colitis 1 

boftening of the small and large intestine and follicu- 
lar enteritis, 2 

Softeningof the sma'i and large intestine and follicu- 
lar colitis, 2 

t<oftening of the small and large intestine and follicu- 
lar entero-colitis 3 

l.olitis, softening of the small intestine and follicular 

enteritis, 1 

Colitis, softening of the small intestine and follicular 

colitis, 3 

Colitis, softeningof the small intestine and follicular 

eptero-colitis, 3 



d s'ofteningof the great intestine, and 



Entero-colitis an 
follicular enteritis ' 

E-VTERiTis IK THE APULT. — In describing this 
form of the disease we find the same difficulty in 
separating its symptoms from those of gastritis, on 
account of the frequent combination of the two 
affections. We still want a scries of cases, observed 
with a view to this particular point, which, however, 
is not of very great practical importance ; for the 
existence of inflammation being recognized in the 
digestive tube at any point of its extent, the general 
principles of treatment are essentially the same. 

We have already stated that the symptoms are 
found to vary with the portion of the tube affected ; 
thus in the following affection the phenomena are 
often peculiar. 

Duodenitis* — This may be an acute or chro- 
nic disease, and rarely occurs without more or less 
of inflammation of the stomach. Hence the term 
gastro-duodenitis. It is now pretty generally 
admitted that irritations of the stomach and duo- 
denum have a powerful effect in inducing either 
functional or organic disease of the liver. Indeed, 
in the opinion of some pathologists, hepatic disease 
is almost always secondary to this state, a doctrine 
however which is too sweeping. But it appears 
certain, that in the notions hitherto received of 
affections of the liver, the influence of gastro-duo- 
denitis in their production has been greatly over- 
looked : thus, when jaundice supervenes in the 
course of a gastro-enteriris, we may diagnosticate 
inflammation of the duodenum in most cases, and 
we shall find that to this lesion are to be attributed 
a great number of examples of icterus. This 
duodenitis is quite sufficient to produce the jaun- 
dice, independent of any mechanical obstruction 
to the flow of the bile, or the occurrence of an 
acute inflammation of the liver ; and the yellowness 
appears to arise either from the direct transmission 
of inflammation along the ducts, or, according to 
Ribes, by the branches of the porta, or what is 
more probable, from the sympathetic irritation of 
the liver, an irritation which will produce a com- 
plete jaundice, without arising to the degree of 
actual inflammation of the organ. This is the 
doctrine of Broussais ; but the fact that many 
cases of the most acute hepatitis will occur with- 
out jaundice, renders it probable that we must 
seek some other cause than the mere degree of 
irritation, to explain the phenomenon. 

In the third volume of the Dublin Hospital 
Reports, Dr. Marsh details several cases of this 
form of jaundice, and insists on the importance 
of the state of the intestinal mucous membrane. 
In his cases, the usual cause of the affection was 
the drinking of cold fluids when the body was 
much heated, or the sudden and repeated exposure 
of the surface to cold after a similar slate, — causes, 
among the most powerful in inducing gastro-intes- 
tinal inflammation. He there instances, also, the 
patients were generally aihng for some days before 
the jaundice occurred, and the symptoms were 
those of a disordered state of the 'mucous mem- 
brane. The first case detailed presented the dis- 
ease completely predominant in the digestive tube. 
This state was pointed out by the symptoms, 
which were a deeply florid tongue, unquenchable 
thirst, epigastric tenderness, anorexia, or at other 



ENTERITIS. 



51 



times a canine aj)petite, great prostration, rapid 
emaciation, and dysentery. We have seen jaun- 
dice apparently connected with an acute inflam- 
mation of the gastro- duodenal surface, under two 
circumstances. An individual is seized, after an 
excess at table, or other exciting causes, with 
symptoms of fever with decided indications of an 
irritated state of the stomach. There is prostra- 
tion, thirst, general pain, vomiting, anorexia, foul- 
ness of tongue, diarrhoea, or constipation. The 
epigastrium is generally tender, somewhat full, 
and a dull pain is often felt in this situation. 
These symptoms may continue for a time, vary- 
ing from a few hours to several days, when the 
patient becomes deeply jaundiced. At this time 
the heat of skin may subside, but the prostration 
generally continues much longer. By judicious 
treatment this case generally does well, but if not 
relieved the affection may be fatal ; and in the 
great majority of cases, death takes place more 
by an extension of disease through the intestinal 
tract, or by sympathetic irritation of the brain, 
than by the production of an acute hepatitis. 
This appears to be one of the most frequent forms 
of jaundice ; and the symptoms, as to intensity, 
may vary from a very slight to a severe dis- 
ease, accompanied with remarkable indications of 
irritation of the nervous system. Coma is a 
frequent and most unfavourable symptom ; and 
we have observed delirium and tetanic shocks to 
occur. 

The second case in which we have seen jaun- 
dice connected with an inflamed state of the gas- 
tro-intestinal mucous membrane, was observed in 
a good many instances during the last epidemic 
of fever in Dublin. In the Meath Hospital, Dr. 
Graves and the writer of this article treated many 
of these cases, which, from the dreadful severity 
of their symptoms, and their almost complete 
analogy with the yellow fever, excited the greatest 
interest. Of this fatal fonn of disease, the fol- 
lowing description is abridged from the report of 
the Meath Hospital, printed for the use of the stu- 
dents of that institution. 

" In all the cases, symptoms of gastric fever, of 
greater or less intensity, preceded the yellowness 
for a few days, and without an exception, the su- 
pervention of the jaundice was ushered in by a 
great exacerbation of the symptoms of gastro-in- 
testinal inflammation. The patient, often without 
any premonitory indications of the approaching 
danger, became seized either with spasms of the 
abdomen, called by the nurses " twisting of the 
guts,^' a wme which agreed singularly with the 
morbid ippearances found after death, or with 
merely hardness and extreme tenderness of the 
epigaj'.iium and hypochondria. This hardness, 
accompinied with a knotted feel of the abdominal 
muscle^ was speedily followed by universal jaun- 
dice, ge.jeral uneasiness, anxious expression of 
countenance, a hurried pulse, cold extremities, 
and death, commonly within twenty-four hours 
from the af)p-arance of the jaundice. About one- 
half of the persons so afl'ected raved and betrayed 
great restlessness, while the remainder seemed in 
perfect possession of their intellectual faculties to 
the last, but at the same time appeared in a most 
nervous, irritable, and desponding state of mind. 
They could not rest for a moment tranquil, but 



tossed their arms about and looked at their attend- 
ants with an expression of suffering and despair. 
Most of them vomited, and in two cases a matter 
resembling coffee-grounds was discharged from 
the stomach and bowels. The tongue was parch- 
ed, and in some instances covered with a black 
coating; and in one patient, the attempt to swal- 
low produced general spasms. In all, the most 
exquisite tenderness of the epigastrium existed ; 
and in several the tip of the nose became purple, 
giving to the countenance a truly frightful appear- 
ance, particularly when it spread from the nose to 
the upper portions of the cheeks. This change 
was preceded by pallor and coldness of the part ; 
this was succeeded by a leaden hue, and in twelve 
or twenty-four hours the purple hue was complete. 
The toes were in some cases similarly affected ; 
and where the patients recovered, a partial destruc- 
tion of parts resulted from the disease. On dis- 
section the appearances in all the cases were re- 
markably similar. The mucous membrane of the 
stomach and duodenum was found in an intense 
state of inflammation, which also extended more 
or less into the small intestines, where numerous 
recent intus-susceptions were constantly found. 
The spleen in almost every case was greatly en- 
larged and softened, but in none did we find evi- 
dences of inflammation of the liver, or obstruc- 
tion of the gall-ducts. Slight yellowish effusion 
below the arachnoid was found in several cases ; 
and in one there was a remarkable dryness of the 
arachnoid. Such were the appearances in about 
fifteen cases of this disease. There were some 
cases in which general convulsions were reported 
to have occurred, but we could not corroborate 
this by personal observations. In every case a 
general hardness and knotted feel of the abdomi- 
nal muscles, with extraordinary tenderness of the 
epigastrium and hypochondria, were observed. 
This was often so extreme as to make us suspect 
the existence of peritoneal inflammation ; yet on 
dissection no instance of this lesion occurred. 
The bad symptoms generally came on without 
any indication of the approaching danger ; the 
intestinal spasms being speedily followed by gene- 
ral jaundice of various degrees of intensity ; and 
in the fatal cases death took place in a space of 
time varying from six to twenty-four hours. In 
every instance the patients sulfcred from extreme 
thirst, and there was nausea, and frequently vom- 
iting, and in one case the genuine black vomit 
occurred for some hours before death." 

With respect to the cause of the jaundi#3 in 
these cases, we are more disposed to connect it 
with the severe gastro-intestinal inflammation than 
with any other lesion. Perhaps the violent spas- 
modic action, by constricting the orifices of the 
ducts, might have had some effect ; but the fact 
that many of the patients had bilious stools, and 
our commonly finding bile in the intestines, is 
against this supposition. That it did not depend 
on hepatitis is certain, as in no case did we iliitl 
marks of inflammation in the liver. That the 
liver in such cases is more or less irritated is pro- 
bable from the sympathy which it possesses with 
the gastro-intestinal mucous membrane, but in 
both cases this irritation is secondary, and seldom 
amounts to actual inflammation. In one caso 
hepatitis was observed, but the patient was n<^ 



62 



ENTERITIS. 



under our care ; anJ symptoms of suppuration of 
the liver, with discharge of the matter through 
the lungs, occurred in one of our convalescent 
patients. In this case perfect recovery followed. 
In no instance did any of the attendants of the 
hospital contract this form of fever; from which 
circumstance we conclude that the change of cha- 
racter did not increase the contagious nature of 
the disease. 

In this country, where it is so usual to attribute 
many complaints to affections of the liver, it is of 
great importance that the connection which com- 
monly exists in the relation of cause and effect, 
between irritations of the upper part of the diges- 
tive tube, and derangements of the hepatic func- 
tion, should be carefully studied. It is true that 
gastro-duodenitis may exist without jaundice, or 
that hepatic inflammation may arise independent 
of disease in the mucous membrane ; but it is 
equally true that the symptoms of gastro-duodeni- 
tis, both acute and chronic, are those commonly 
received as indicative of hepatic disease ; and that 
this last affection may commence by inflammation 
in the digestive tube. These principles must be 
borne in mind ; and in the treatment of such 
affections, if any doubt exists as to the diagnosis, 
it is better to give the patient the advantage of 
that doubt; to treat the patient for gastro-duo- 
denitis before we have recourse to the hazardous 
modes supposed to be useful in hepatic disease. 
It constantly happens that cases of chronic gastro- 
duodenitis are treated as disease of the liver. 
This, if proper practice was pursued, would not 
lead to any serious injury, as the* principles of 
treatment in both affections should be essentially 
the same ; but where purgatives and mercurials 
are blindly lavished, without regard to the state 
of parts or the constitution of the individual, the 
distinction becomes of no slight importance to the 
safety of the patient and the character of medicine. 
Inflammation of the Jejunum and IIeum« 
— It is dilficult to lay down the symptoms of 
this affection, from its frequent combination with 
disease in the stomach and colon ; but where the 
disease is predominant in this part of the tube, 
the symptoms are generally the following : thirst, 
often without any vomiting, tympanitis, tender- 
ness on pressure, pain, when present, not severe. 
In fact, if we abstract the symptoms of irritation 
at the upper and lower portion of the tube, such 
as vomiting and diarrhoea, we may have the 
remaining signs of intestinal inflammation arising 
from this cause. It would, however, be wrong 
to conclude that vomiting and diarrhoea always 
point out an extension of disease to the stomach 
and colon; the contrary is the fact; but as a 
general rule the existence of these symptoms 
should lead us to suspect that the disease is not 
confined to the small intestines alone. 

When the disease is severe, we commonly ob- 
serve stupor, a red tongue, great thirst, tenderness 
on pressure, tympanitis, which is often excessive 
and occurring at an early period of the case, ten- 
derness on pressure princi[>ally observable in the 
hypogastric and iliac regions. Dianho-a may be 
present or absent, but the latter is, we believe, the 
most frequent case. The pulse is generally small 
and frequent, and the features are contracted. In 

casfi of inflammation of the ileum in its lower 



third, which lately came under our notice, the 
abdominal symptoms were great tympanitis, pain 
on pressure, and thirst, without vomiting. In the 
commencement of the case there was some diar- 
rhoea, but this soon subsided, and was succeeded 
by constipation. On dissection, the stomach and 
colon were found perfectly free from vascularity ; 
but the lower portion of the ileum presented a 
vast number of extensive ulcerations. In this 
case, the absence of vomiting and of diarrhoea in the 
more advanced periods is ext'^emely interest- 
ing, as connected with the healthy state of the 
stomach and colon. We have more than once 
observed, in examining the bodies of phthisical pa- 
tients who never had diarrhoea, that the ulcerations 
and other marks of inflammation were confined 
to the ileum alone. In the present state of our 
knowledge it appears, that in cases of inflamma- 
tion of the ileum, the absence of vomiting and 
diarrhoea seems to imply a healthy state of the 
stomach and colon ; but on the other hand, these 
symptoms may occur independentlj' of disease in 
these portions of the tube. 

The symptoms arising from sympathetic irrita- 
tion vary with the idiosyncrasy of the patient and 
the intensity of the disease. There may be a vio- 
lent continued fever, a remittent or hectic fever, 
or a completely apyrexial state. We have known 
one case where the most prominent symptom was 
so violent an excitement of the heart as to lead to 
the belief that pericarditis and hypertrophy of the 
organ existed. In the Meath Hospital we have 
often observed increased pulsation of the abdomi- 
nal aorta in these cases, a symptom which has 
not been sufficiently attended to. Here the exci- 
ted state of the vessel seems analogous to that of 
the radial artery in cases of whitlovk^, and may be 
perceived even where the belly is not collapsed. 
Under proper treatment this subsides, with the 
other signs of abdominal irritation. 

In the inflammation of the small intestines in 
the adult, cerebral excitement is generally not so 
prominent a symptom as in that of the child, nor 
is it so often followed by structural disease of 
the brain. It is sometimes very difficult to say 
whether symptoms of irritation of the brain, under 
these circumstances, are really indicative of actual 
inflammation of that organ. Andral relates a case 
where the patient, aged 35, was attacked with 
pain of the head, followed by great loquacity and 
exaltation of ideas, and other symptoms of cere- 
bral excitement. The tongue was natural, and 
the abdomen soft and not painful. He had soon 
after furious delirium, and indications of strong 
determination to the head. Copious general bleed- 
ing, and the application of leeches to the neck, 
produced no alleviation ; and the patient expired 
suddenly in the midst of a general spasm. The 
only local symptom of an affection of the bowels 
during the disease was a slight diarrhoea. On 
dissection the brain and its membranes were found 
perfectly healthy ; but the lower third of the ileum 
was in a state of acute inflammation. 

Other instances of anomalous symptoms might 
be quoted. In many cases the disease is termed 
simple continued fever, and extensive destruction 
may be going on without the occurrence of any 
decided local symptoms. The affection, however, 
should be suspected, if in addition to the genera) 



ENTERITIS, 



53 



symptoms there is much thirst, tympanitis in the 
early stages, and irregularity of the bowels, which 
are sometimes constipated, or the contrary ; the 
state of the evacuations does not afford much in- 
formation, as fatal cases have occurred where they 
continued perfectly natural. It is in these cases 
that the excess of the system of purgative treat- 
ment is so liable to do injury. We believe that 
many patients are thus lost ; ulcerative perforation 
being induced, or the disease aggravated and ex- 
tended to the colon. We have also constantly 
seen the exhibition of turpentine, with the inten- 
tion of relieving the tympanitis, produce the very 
worst consequences. As a general rule, this sub- 
stance should never be exhibited in the early stage 
of a febrile affection where tympanitis exists. 
This is the disease described by Petit, under the 
name of the eniero- mesenteric fever, of which the 
following accurate description should be borne 
constantly in mind. " There is at first a feeling 
of debility and general illness, with anorexia and 
irregular attacks of fever, but more often diarrhoea. 
The countenance is expressive of prostration and 
dejection ; the eye dull, and the skin pale and 
livid, particularly about the lips and the ala; nasi ; 
decubitus on the back ; disinclination to motion ; 
skin dry and harsh; torpor, and a certain degree 
of prostration of the intellectual faculties. The 
fever is obscure in the course of the day, but 
gradually comes on in paroxysms, without rigors 
or much heat, but with injection of the eye and 
slight delirium ; there is great thirst, the teeth are 
drj', and the tongue is covered with a greyish 
paste : the stools are bilious or serous, variable in 
their frequency or abundance, but not sufficient 
to account for the prostration of the patient ; belly 
soft and not swollen ; little or no pain, but on 
pressure pain is felt generally on the right side, 
between the umbilicus and crest of the ileum : 
there is retraction of the lips and alae nasi. The 
symptoms gradually increasing, we observe the 
cheeks to become livid, the eyes are sunk and in- 
jected, and somnolence and delirium become con- 
stant, although the answers of the patient, though 
painful, are correct. Pelechiae, subsultus tendi- 
num, and continued fever, with nocturnal exacer- 
bations, supervene ; the pulse is frequent and 
easily compressed ; the teeth are covered with 
sordes, and the tongue with a brownish or black 
crust ; the belly becomes more painful, the pain 
being sometimes still confined to its original situa- 
tion, and without tympanitis, at other limes more 
extended and with meteorism. The alvine evacu- 
ations become serous, fetid, and frequent, and the 
urine is scant)'. Excoriations of the nates com- 
mence, and where the patient has been blistered 
there is a tendency to gangrene." 

On dissection, the digestive tube is generally 
found healthy until we arrive at the middle of the 
ileum, which presents all that class of appearances 
constituting the exanthcme interne of the French 
pathologists, the duthinenteritis of Bretonneau. 

This disease appears to be a common cause of 
what is termed an imperfect convalescence in 
fever. A patient, after suffering fi'om fever for 
some time, becomes so much improved, that a 
speedy convalescence is hoped for ; but in a few 
days it is found that strength is not returning, the 
pulse continues quick, and the appetite, though 



sometimes restored, is more often deficient and 
capricious. A degree of stupor comes on, and 
there is an occasional flush on the check. Under 
these circumstances there is often reason to sus- 
pect this disease of the ileum, which may go on 
insidiously to a fatal termination, or suddenly de- 
stroy hfe by ulcerative perforation. Dr. Cheyne 
describes these cases in his Report of the Hard- 
wicke Fever Hospital for 1817, from which we 
extract the following important remarks : — 

" In these cases the distress of the patient often 
bore no proportion to the danger he was in ; the 
former was very little, while the latter was ex- 
treme. The disease would proceed without vio- 
lent symptoms; nay, a patient would seem to be 
recovering, although without any critical dis- 
charge: he would call for full or middle diet, and 
for days take his food regularly. The only cir- 
cumstance in his situation which demanded atten- 
tion was that he regained neither strength nor 
flesh ; he ex[)ressed no desire to leave his bed. 
Then his pulse again became quick and his 
tongue dry, and he would complain of dull pain 
and uneasiness in his belly, attended with sore- 
ness on pressure, and a degree of fulness in the 
upper part of the abdomen. Then came on a 
loose state of the bowels and great weakness : 
probably at the next visit the patient was lying 
on his back, with a pale sunk countenance and a 
very quick feeble pulse ; his mind without energy. 
Then the stools (jnucon.s') passed from him in 
bed, and the urine also ; perhaps a hiccup came 
on; next his breathing became frequent, in which 
case death was at no great distance. Attempts to 
check the diarrhcca by astringents and opiates, or 
to rouse the patient by cordials, were alike una- 
vailing ; such remedies only seemed to accelerate 
death." 

Dr. Cheyne states that in all these cases the 
mucous membrane and glands of the intestine 
were found in a state indicating decided inflam- 
mation during life. See also Andral, Clinique 
Medicale. 

The history and symptoms of inflammation of 
the large intestine, colitis, are described in the 
article Dtsenteht, to which we refer, 

[A few remarks may be made, however, upon 

Inflammation of tlie Ctecum, to which 
great attention has been paid by pathologists, of 
late years more especially. To this the names 
Typhlitis and Typhlo-enteritis have been given. 
This inflammatory condition has already received 
some notice under Constipation, (p. 484.) 

Simple acute inflammation of the lining mem- 
brane of the caecum may be an accompaniment of 
colitis or dysentery ; but it may occur independently 
of these. The most marked symptoms are, violent 
pain in the right iliac fossa, increased on pressure, 
by which it is rendered lancinating. The pain is 
constant, and often proceeds in the direction of 
the ascending colon. The evacuations are copiou« 
and frequent, sometimes from ten to twenty in the 
day, and are mucous or bloody, or both; and, 
along with these symptoms, there is generally 
gastric disturbance and fever, the pulse being 
accelerated and hard, the skin hot and dry, and 
the urine high-coloured, as in ordinary cases of 
severe internal inflammation. 

Inflammation may likewise attack the peritoneal 



64 



ENTERITIS. 



coat solely, or along with all the coats of the 
intestine, and these are the cases to which atten- 
tion has been mainly airected of late years. They 
are attended with more or less tumefaction in the 
iliac region, and are owing to some mechanical 
impediment in the caicum, constituting Typhlitis 
stercoralls. Where the disease affects the perito- 
neal coat, it is marked by the ordinary signs of 
peritonitis, or rather of inflammation of the perito- 
neal coat, of which constipation is one. The 
inflammation may extend to the cellular tissue 
surrounding the caecum — Perityphlitis — and is 
indicated by an inflammatory pain in the iliac 
region with distinct hardness, constipation and 
numbness 6f the thigh — owing to the tumour 
pressing upon the nerves as they pass down to the 
right lower extremity — and occasionally retraction 
of the testicle. This form of the disease may 
terminate by resolution, or in any of the results 
of cellular inflammation. Pus may form and be 
discharged into the csBCum, or into the cavity of 
the abdomen ^ or perforation may take place 
through the intestine and the parietes of the abdo- 
men ; and where the disease terminates fatally, a 
large cavity is generally observed in the vicinity 
of the CEECum, separated from the cavity of the 
abdomen by the peritoneum. In a case, which 
fell under the writer's care, the pus was discharged 
into the urinary organs, and the female recovered. 

Idiopathic inflammation of the caecum from 
ordinary causes, as from exposure to vicissitudes 
of weather, is certainly rare. Yet the author has 
observed three or four cases in which no other 
cause could be assigned than such as might have 
induced inflammation in any other part of the 
digestive tube or of any internal organ. 

The symptoms, that indicate typhlitis induced 
by mechanical causes, are — very decided evidences 
of local inflammation coming on without any 
very obvious cause, when the patient is in health ; 
and the comparatively slight implication of the 
general system, as shown by the greater or less 
freedom from fever. The pain commences in the 
verj' seat of the csecum ; gradually augments for 
from twelve to twenty-four hours, and is constant. 
Careful examination now shows fulness and ten- 
sion of this part of the abdomen, with tenderness 
on pressure, and dulness on percussion ; the bow- 
els are constipated, and the functions of the sto- 
mach disturbed. The general system now sym- 
pathizes, and the ordinary symptoms of internal 
inflammation declare themselves. Any motion of 
the body induces pain, so that the patient Ues on 
his back, inclining towards the right side, with 
the thigh bent on the abdomento to relax the 
abdominal parietes. The symptoms go on in this 
manner for some days, the affection gradually 
extending, more or less, over the abdomen, wbich 
now becomes full and tense. The pain over the 
cacnm is lancinating, and the slightest touch with 
the finger, or the slightest covering, excites excru- 
ciating torture. Still, the danger does not seem so 
imminent as in acute enteritis, although in the 
sequel it may prove equally fatal. 

It is obvious, that a favourable termination of a 
case of this kind cannot be expected until the 
mechanical impediment yields; but if this be 
removed, all t!ie symptoms soon vanish. This, 
iiowever can rarely be accomplished in less than 



a week. About this period, it may happen that, 
if the bowels have not responded to the means 
employed, the patient's strength declines and he 
dies ; and it has been conceived by one writer, — 
Dr. Burne, — that if much blood has been ab- 
stracted, he may sink rather from exhaustion than 
from the effect of the inflammation : this, however, 
is scarcely probable ; but if life be prolonged, 
there may be discovered, about the tenth day, a 
circumscribed emphysematous tumour in the right 
ilio-inguinal region, or posteriorily in the corre- 
sponding ilio-lumbar region, which is a faecal 
abscess making its way to the surface. If in the 
former case, the peritoneum must be perforated 
after adhesions have been formed around the part 
to be perforated ; if in the latter, the abscess tends 
upwards and backwards towards the least resisting 
part of the lumbar parietes, which is at the outer 
edge of the quadratus lumborum muscle. In this 
way, the abscess may be discharged, and recovery 
take place, or the patient may die worn out by 
irritation. 

Perforative abscess of the caecum must be 
esteemed a serious malady. Of seventy-three 
cases, death occurred in twenty ; and in eleven 
others, the symptoms were so severe as to threaten 
life. Stercoraceous abscesses appear to be the 
most fatal, the ratio being five in seven, according 
to M. Grisolle. 

Inflammation of the Appendix Verml" 
formis Cseci. — The appendix vermiformis, the 
use of which is so obscure, and its presence even 
by no means indispensable, communicating, as it 
does, with the caecum by means of an open ex- 
tremity, may have substances impacted in it, 
which give rise to inflammation and perforative 
ulceration, attended with fatal consequences ; for 
although adhesion may take place between it and 
the peritoneum lining the parietes of the abdomen, 
the more common result is for the abscess to 
break into the cavity of the peritoneum, and to 
induce fatal peritonitis. 

The symptoms which indicate this affection 
are by no means diagnostic. Generally, there is a 
deep-seated pain in the ca;cal region, with more or 
less fever, vomiting and obstinate constipation. 
The pain is aggravated by pressure ; and careful 
examination exhibits tumefaction, which may be 
unhesitatingly referred to the caecum or to its 
appendix ; at other times, the inflammation 
spreads over the whole of the peritoneum, so that 
the diagnosis, when the physician is first called, 
may be— peritonitis, general or partial. 

The position of the appendix is not always the 
same; a fact which must be borne in mind. 
Generally it is curled up beneath the cjecum, con- 
cealed by It, and on the outer side of the psoas mag- 
nus muscle ; and, according to its position, different 
parts m its vicmity may be prominently impU- 

It has been already remarked, that the affection 
may be mduced by small substances becoming 
impacted m the appendix. In one instance, it 
was an mtestmal concretion; in another, a pin, 
encrusted w.th a calculous deposit : in an;ther, a 
chery-stone; in another, a grape-stone , and, in 
another, a tooth, which had been swallowed 

Ihe appendix has been found perforated -a 
portion having sloughed away-with evidences of 



ENTERITIS. 



55 



a high degree of mischief, the result of inflamma- 
tion ; as eflusion of coagulable lymph, suppura- 
tion, or gangrene, in the neighbouring parts. 

Inflammation of the Colon. — This, like 
inflammation of the rest of the intestinal canal, 
may afiect either the peritoneal or the mucous 
coat. When seated in the latter, we have the 
phenomena of dysentery, (q. v.) 

When the peritoneal coat is inflamed, there 
may be constipation, and the usual signs of exo- 
enteritis, except, that the mischief is referred to 
some part of the colon, — the ascending, transverse 
or descending portion, and that the affection of the 
general system is much less than when the same 
pathological condition is seated in the small intes- 
tine. The nearer, too, the inflammation is to the 
rectum, the less acute and violent is the disease. 
"When in the transverse colon, it is often ex- 
tremely obscure. Commonl)^ there is considera- 
ble pain upon pressure, with more or less disten- 
sion of the colon, meteorism, constipation, vomit- 
ing, great restlessness, along with the signs of 
internal inflammation. 

When colitis passes into the chronic state, we 
may have all the results of chronic inflammation 
of the peritoneal surface of the small intestines, — 
adhesion of the colon to other viscera, thickening 
of the parietes of the intestines, with diminution 
of the caliber, — at times, to such a degree as to 
occasion obstruction, and death, &c. «&c. 

Many morbid conditions, that are referred to 
the stomach or liver, have their seat in the colon. 
Owing, too, to the attachments of the colon, and 
its immediate proximity to several important 
organs, its unequal distension and frequent 
changes of position, various sympathetic affections 
are induced, the nature of which is often mis- 
understood.] 

The foregoing view of the symptoms of inflam- 
mation of the mucous membrane of the intestine 
will suffice to give a general idea of the disease, 
of which, however, there are many other modifi- 
cations. To enter more fully into these would 
occupy too much space, and hence we shall pass 
at once to the consideration of the pathological 
anatomy of the digestive tube. Now, in order 
properly to estimate the morbid, it is necessary, in 
the first instance, to take a view of the healthy 
condition of this organ. 

It is now demonstrated that a great variety of 
shades of colour may exist in the mucous mem- 
brane, independently of any diseased action what- 
soever. The situation of the part, the age of the 
patient, the process of digestion, and the length 
of time after death, will all modify the colour of 
this tissue. Its natural colour, however, may be 
stated to be greyish-white in the duodenum and 
jejunum; the greyish tint diminishes to the end 
of the ileum, and in the large intestine the colour 
is white. This may serve for a general descrip- 
tion. When we examine the intestinal mucous 
membrane of the foDtus, we find it of a rosy colour, 
which diminishes after birth ; in youth, the white 
colour becomes gradually less vivid ; and as the 
individual advances in age, the greyish tint be- 
comes manifest. 

The mucous membrane, however, is seldom 
met with so slightly coloured, and when we speak 
of the value of redness as a sign of disease, we 



shall examine the various sources of this change 
of colour. 

In the state of health the gastro-intestinal mu- 
cous membrane varies in its thickness, according 
to the part of the tube examined. Billard has 
described it as most thick in the duodenum, and 
the thickness as diminishing in the following order 
of parts : the stomach, rectum, jejunum, ileum, 
and colon, where it is thinnest : it is obvious, 
however, that unless the increase or diminution 
of thickness be considerable, its value in a patho- 
logical view cannot be great ; and, independent 
of intestinal disease, it may present appreciable 
differences. Thus, in cases of great emaciation, 
the atrophy of the membrane is often extreme, 
while in examples of mechanical congestion its 
thickness is frequently much increased. Louia 
has attempted to determine the exact depth of the 
mucous membrane by measurement ; but this is a 
mode not applicable to general use. As to its 
consistence, this is stated to be in the direct ratio 
of the thickness ; hence, if in those situations 
where the membrane has naturally the greatest 
thickness, we find its consistence only equal to 
the thinner portions, it is plain that from some 
cause this has been diminished. It is difficult to 
meet with cases on which to try the accuracy of 
this assertion. We have been led to doubt il 
more than once, but the impediments to the in- 
vestigation are very considerable ; the greatest 
experience is required to enable us to decide on 
the healthy consistence of the part ; and we seldom 
meet with the tube free from some active or passive 
congestion : add to this, that many other circum- 
stances cause variations in the cohesion of the 
membrane, such as the presence of liquids in the 
tube, putrefaction, atmospheric heat, and a fluid 
state of the blood. The mucous follicles have 
lately attracted the particular attention of patholo- 
gists ; and to their inflammation several remarka- 
ble disorganizations may be referred. Thus, in 
very many cases of intestinal ulceration, the de- 
structive process seems to be primarily seated in 
these glands. Bretonneau has indeed described a 
peculiar disease, called by him dothin-entej-itis, 
consisting in an inflammation of these glands 
alone; but it is still to be shown whether this 
disease in reality differs from other examples of 
intestuial inflammation. In these countries the 
writings of Drs. Hewett, Bright, and Abercrombie 
have contributed to draw the attention of physi- 
cians to these glands. 

We find these bodies, in the state of health, 
most developed in the duodenum and stomach, 
and in some cases also the glands of Peyer are 
observed distinctly in the small intestine. This is 
more remarkable in children, but still their en- 
largement alone in the adult must not be consi- 
dered as an unequivocal indication of former or 
actual disease. 

Lastly, we have the sub-mucous and sub-seious 
cellular membranes, and the two orders of muscu- 
lar fibres, in which tissues disease may produce a 
great increase or diminution of volume. The 
muscular fibres are compared by Andral to the 
muscles of white-blooded animals, and are found 
strongest at the pyloric portion of the stomach 
and in the rectum. This tunic of course appears 
thicker where the intestine is contracted, a.'vJ 



56 



ENTERITIS. 



like the heart, may become atrophied in cases of 
general emaciation. We often, indeed, meet with 
cases where the demonstration of these fibres is a 
matter of great difficulty. 

The natural condition of the intestine is a col- 
lapsed but pervious state. Dr. Abercrombie, in 
his theory of ileus, holds that the cord-like con- 
traction is the normal condition of the part; but 
in this opinion he is completely singular : con- 
traction of a muscle implies the communication 
of a stimulus, and cannot be considered as its 
natural slate. 

But the consideration of these tissues alone 
will throw little light on the physiology or patho- 
logy of the intestinal canal, if we do not take into 
account that its surface presents a prodigious 
vasculo-nervous expansion, where, in a manner 
analogous to the retina in the eye, or the portio 
mollis in the internal ear, the (sentient) extremities 
of the organic nerves, and to a certain degree of 
those of the life of relation, are extended. It is, 
to use the words of Broussais, an internal sense, 
and thus can be understood its numerous sympa- 
thies in health and disease. 

There is no organ in the body where the deter- 
mination of the value of morbid appearances is so 
difficult, and hence it is necessary to investigate a 
great number of circumstances before we can say 
whether the mucous membrane has or has not 
been in a state of disease. In general these diffi- 
culties are not sufficiently estimated ; and it is to 
be regretted that one class of pathologists are too 
hasty in ascribing every change from the physiolo- 
gical condition to a process of irritation ; in these 
countries, indeed, vascularity alone is too often 
taken for an unequivocal indication of the previous 
existence of inflammation, a circumstance which 
invalidates many of our accounts of morbid changes 
in the digestive system. We shall see that vascu- 
larity alone, in all its forms, does not prove the 
previous existence of inflammation ; and that, fur- 
ther, the converse of the proposition will sometimes 
be found to be true. It may be laid down as a 
general principle, that no morbid appearance what- 
soever, taken singly, is a certain proof of the oc- 
currence of inflammation. Even ulceration, per- 
haps the most certain of all, may occur under 
circumstances in which it is difficult, if not im- 
possible, to trace it to an inflammatory origin. 

The following are the results of inflammation 
on the intestine : — 1. Increased vascularity, or 
hjperemia. 2. Increase or decrease of develop- 
ment. 3. Induration, or softening. 4. Ulcera- 
tion 'i rihange of secretion in quality or quan- 
tity. 6. Alterations of sensibility. 

Vascuhr-'ify. — The great principle to be recog- 
nised in determining the value of this condition, 
as a proof of inflammation, is, that there is no- 
thing in its intrinsic characters sufficient to point 
out the nature of its origin. Many authors have 
described certain kinds of injection indicative of 
active or passive congestion ; but the researches 
of Andral have shown that the distinctions relied 
on are by no means certain, and this also is the 
result of our experience. By a careful examina- 
tion, however, of the concomitant circumstances, 
we shall, in most cases, be enabled to decide the 
question. Capillary injection, putting aside some 
nf its rarer sources, may generally be stated to 



arise from one of the following causes :— 1. ac- 
tive irritation ; 2. congestion from abstraction of 
the venous circulation ; 3. congestion from posi- 
tion. We may compare, by opposite characters, 
the inflammatory and non-inflammatory redness. 

Non-injlammatory 
redness. 



Inflammatory 
redness. 

1. Occurring indifferent- 
ly in the depending or 
non-depending portion 
of the tube. 

2. General injection rare. 



3. Without 
struction. 



oh- 



Most distinct in the 
depending position. 



2. General injection com- 
mon. 

3. Commonly arising 
from obstructions in 
the porta, heart, or 
lungs. 

4. Generally occupying 
a large portion of the 
intestine. 

5. Without much soft- 
ening. 

6. Without these altera- 
tions. 



4. Sometimes slight and 
local. 

5. With softening of th 
submucous cellular 
membrane. 

6. With alterations in 
the quality or quanti- 
ty of mucus. I 

By means of this table, which, with some alter- 
ations, is taken from the work of Billard, we may 
in most cases determine the nature of vascularity 
occurring in the intestinal mucous membrane. 
The presence or absence of ulcerations, of fun- 
goid elevations, of lymph, the state of the submu- 
cous follicles, the occurrence of thickening, and, 
lastly, the history of the case, will aid further in 
deciding the question. It has been remarked that 
the active and passive congestion differ in the cir- 
cumstances of their formation ; in the latter the 
injection proceeds from the large vessels, which 
are first distended to the capillaries, while in the 
former the reverse takes place. This may be a 
test in the earlier stages of the process. 

From the consideration of the different causes 
of redness in this tissue, it would appear that be- 
fore we conclude that vascularity in any case is 
an unequivocal sign of inflammation, we must in 
the first instance inquire whether it is not the re- 
sult of the process of digestion ; secondly, whe- 
ther it may not be owing to a fluid state of the 
blood, as observed by Morgagni ; thirdly, whether 
it arises from putrefaction, exposure to air, or the 
depending position ; fourthly, whether it is the 
result of the congestion which occurs immediately 
before death in tissues abounding in vessels; 
fifthly, whether it is caused by obstructions in 
the aorta, heart, lungs, cava, or vena porta. Other 
causes of redness, independent of inflammation, 
are noticed, but they are not of great im})ortance, 
except in the case of a patient dying in the cold 
stage of intermittent, where the viscera are found 
loaded with blood. These considerations show 
the difficulties that exist in the decision of this 
question, and should make us doubt the reports 
of inflammatory appearances in the digestive 
tube, unless made by the most experienced patho- 
logist. 

The shades of colour which are produced by a 
process of irritation are very numerous, but may 
be reduced to modifications of red, brown slate- 



ENTERITIS 



57 



coloured, and black ; of these, the first is most 
commonly, though by no means universally, the 
product of an acute inflammation, while the three 
last are nearly exclusively the result of a chronic 
process, in which the colouring matter of the 
blood, variously altered, becomes incorporated 
with the tissue of the mucous membrane. Of 
the red colour, Billard enumerates six varieties, 
viz., the ramiform and capillary injection, the 
jjunctuated and striated redness, that occurring in 
patches, and, lastly, the diffuse. Bearing in mind 
that all these may be the result of other causes 
besides irritation, and that we must look to the 
concomitant circumstances to decide upon their 
nature, we must admit, with the author just men- 
tioned, that the first of these, consisting of a very 
slight injection, must be the result of a feeble irri- 
tation, one to which the flux is by no means con- 
siderable. In the second species the injection is 
finer and closer, and points out a much higher 
degree of irritation. This is often seen in the 
neighbourhood of ulcerations. The punctuated 
redness is less common in the" intestines than in 
the stomach ; its appearance may be compared to 
that produced by finely sprinkling a surface with 
red paint, and it does not point out an intense de- 
gree of irritation. As to the striated redness, we 
have most usually found it in cases of chronic 
enteritis, where, for a considerable length of the 
tube, the prominent edges of the valvulae conni- 
ventes were of a deep red colour, giving to the 
intestine the appearance of circular stripes. It 
sometimes coincides with a puriform secretion and 
an indurated state of the submucous cellular tis- 
sue. The last two species are the most import- 
ant ; here the vascularity is intense ; so much so 
as to obliterate the traces of the capillary vessels, 
and give to the membrane a continuous blood-red 
colour. They may both be the product of an acute 
or chronic inflammation, but generally arise from 
the first cause. The diffuse redness is sometimes 
found of great extent, and points out a most se- 
vere disease. We have often seen the mucous 
membrane, in such cases, exactly similar to the 
conjunctiva of the eye-lids in the worst forms of 
purulent ophthalmia. This appearance was found 
in most of that singular set of cases, greatly re- 
sembling the yellow fever of warm climates, 
which were observed at the Meath Hospital dur- 
mg the late epidemic of fever. It is the result 
of the highest degree of idiopathic inflamma- 
tion ; it is no longer an injection, but an active 
ecchymosis. 

The brownish, slate-coloured, and black appear- 
ances of the mucous membrane are generally re- 
Icrreil to a very chronic irritation. The last, in- 
deed, is most commonly seen in cases of diarrhoea 
of long standing, and occurs with other indica- 
tions of a profound morbid action. It is, however, 
seen in some cases of a high degree of acuity, as 
in mstances of corrosive poisoning, and in the yel- 
low fever and dysentery of tropical climates. This 
is important, as connected with the opinion of 
Broussais, where, in speaking of the black colour 
of mucous membranes, he holds that in most of 
these cases an acute had preceded the chronic 
ttate. 

An important question here arises — do these 
ippearances of inflammation always furnish an 
Vol. II.— 8 



accurate measure of its mtensity. We have seen 
that there are circumstances foreign to irritation 
that may increase this vascularity, such as posi- 
tion, mechanical impediments to the venous cir- 
culation, &c. Hence, in certain cases, the appear- 
ance of inflammation may point out a greater de- 
gree of disease than had really existed. But does 
the reverse ever occur ? Can inflammatory in- 
jection exist, and yet wholly or altogether disap- 
pear after death 1 Bichat and Broussais are both 
in favour of this opinion, and hold that although 
no redness may be found in the part after death, 
yet, notwithstanding, it may have been inflamed 
and vascular during life. This is a doctrine of 
importance from the dangerous use which may be 
made of it in pathology. 

It is true that after death the traces of erysipe- 
las will greatly, if not altogether, disappear in some 
cases, and the same has been observed with re- 
spect to the redness of a sore throat. Bichat ex- 
plains this by stating that the injection of the ca- 
pillaries ceases as soon as the irritation which 
caused it becomes extinct with the life of the pa- 
tient, and lays great stress on this point in its ap- 
plication to morbid anatomy. But cadaveric pal- 
lor of parts previously inflamed, though occurring 
in some cases, is far from being a general pheno- 
menon, and where the inflammation has been in- 
tense, as in severe cases of erysipelas or angina, 
the redness will remain long after death. Besides, 
it is scarcely logical to draw conclusions as to the 
viscera, from what occurs on the surface. We 
know that in most cases of death the blood ap- 
pears to forsake the exterior, to accumulate in the 
interior of the body, and that this process goes on 
for some time previous to the extinction of life. 
If this post-mortem emptying of the capillaries 
went on in the mucous membranes as we see it in 
the skin, redness of these tissues should be as rare 
as that of the skin ; but the contrary is the fact. 
We may admit the possibility of this subsidence 
of the appearances of inflammation of the mucous 
membrane in very slight cases ; but looking at the 
phenomena of death in general, we must hold it 
more probable that these appearances will be aug- 
mented rather than diminished on the cessation 
of life. 

But there is one cause for the want of redness 
even where a high degree of irritation has existed 
in parts, namely, the supervention of inflamma- 
tion in other viscera, which, from its excess, causes 
an actual revulsion. Thus, when a bronchitis 
subsides on the supervention of a fatal diarrhoea, 
we may find the bronchial membrane free from 
vascularity, or vice versa. The cause is alluded 
to by Billard. In the severe gastro-catarrhal 
fever, we constantly observe alternations of seve- 
rity in the abdominal and thoracic symptoms, ami 
more than once we have seen cases in the early 
stages of which the symptoms of enteritis were 
severe, but subsiding when the thoracic irritation 
became intense, arid have found the intentinal 
membrane pale, although ulcerations and other 
disorganizations were present. 

With respect to the relative frequency of inflani 
matory redness in different parts of the digestive 
tube, it is agreed that the stomach and lower part 
of the ileum are most commonly engaged, and it 
is remarkable that the two aflbctions often coin 



58 



ENTERITIS. 



cide. This has led to the term gastro-enteritis ; 
a term, however, which cannot be adopted, as the 
coincidence is by no means universal, and as by a 
too great generalization, it leads to an erroneous 
view of the disease. The order of frequency, as 
given by Andral, in the remaining portion of the 
intestine, is as follows : — the cfficum, colon, rec- 
tum, duodenum, superior portion of the ileum, 
and, lastly, the jejunum. 

Increase of development, or hypertrophy of the 
coats of the intestine, is generally the result of a 
process of chronic irritation ; the thickening of 
the mucous membrane which occurs in acute 
affections being more apparent than real, and 
owing to vascular turgescence merely, while that 
in the chronic cases is a true hypertrophy, the re- 
sult of an increase of nutrition. The parts which, 
in acute diseases, are most usually increased in 
bulk, are the mucous membrane, and the glands 
of Peyer and B runner, while all the constituents 
of the tube may become hypertrophied in the 
chronic enteritis. The thickness of the sub-mu- 
cous cellular tissue is rarely altered in acute, but 
commonly in chronic cases. 

When the mucous membrane is hypertrophied, 
we find the cliange to be circumscribed, or the 
contrary, and seldom observe the tissue equally 
thickened. In the large intestine we have com- 
monly found the mucous membrane elevated into 
numerous nodules, of about the size of a pea, be- 
tween which ulcerations, or a lesser degree of 
hypertrophy, existed. Numerous varieties of 
these elevations are described by authors. In 
cases of this hypertrophy the consistence is gene- 
rally increased, and the colour dark : and it rarely 
happens that the change is confined to the mu- 
cous membrane alone ; it occurs much more fre- 
quently in the large than the small intestines. 

But of the forms of hypcrtro[)hy of the intesti- 
nal tunics, that of the sub-mucous cellular tissue 
is the most important. In this state we find it a 
dense white layer, sometimes more than two or 
three lines in thickness, presenting a distinct 
fibrous structure, and giving to the whole tube a 
remarkable feeling of thickness and rigidity. The 
induration is often so great as to cause a grating 
sound when the intestine is divided by the scis- 
sors. The principal seat of this alteration is the 
sub-mucous, but we have often seen it to engage 
also the sub-serous cellular membrane. It is in 
the large intestine that the change is most usually 
observed, where, after chronic dysenteries, it is 
found in conjunction with other disorganizations. 
In the small intestines, however, it may be met 
with, generally partial, and in the vicinity of old 
ulcerations ; but in a few cases of severe chronic 
enteritis we have found hypertrophy of the whole 
cellular membrane from the pylorus to the anus. 
These were cases where severe symptoms had 
continued for months, the patients presenting that 
singular tenacity of life observable in greatly ema- 
ciated subjects. 

To this change is to be referred most of the 
cases of organic stricture of the intestine : indeed, 
when examined anatomically, we can see in this 
disorganization nothing but a partial hypertrophy 
of this tissue, generally traceable to a process of 
inflammation in the mucous membrane. We say 
generallv traceable, for although in the present 



state of the science we must attribute most of 
these cases to this cause, yet in some it may arise 
from a morbid process, not originating in or ex- 
tending to this tissue. These, however, may be 
looked on as exceptions to a general rule, and, a$ 
far as we have seen, seem connected with a dispo- 
sition to cancerous degeneration of the cellular 
membrane, both in the solid and hollow tube. 

This alteration, as a result of chronic enteritis, 
may be met with in all ages, from the infant 
to the octogenarian. It is, however, stated to be 
most common between the ages of thirty-five and 
sixty-five, and that between puberty and the first 
of these periods it rarely occurs. We have already 
alluded to the atrophy of the intestinal tube, a 
change which may be confined to the mucous 
membrane alone, or engage all the coats of the 
intestine. How far atrophy can be referred to a 
process of inflammation does not j'et appear to be 
determined, as there is a difficulty in the circum- 
stances of the general nutrition being impaired in 
these cases. We have seen ulcerations coinciding 
with an atrophy of the intestine, but in all these 
cases great emaciation had existed some time pre- 
vious to death. This atrophy appears always to 
coincide with a softened state of the mucous mem- 
brane. 

Change of consistence is always admitted as 
one of the consequences of inflammation, and, 
with a few exceptions, the rule, that a chronic 
irritation tends to harden, while an acute tends to 
soften parts, is generally found to be true. In 
the gastro-intestinal mucous membrane the latter 
part of this proposition is, in our experience, 
always true ; but we cannot make this statement 
with respect to the first part, the fact being that 
an indurated or softened state may result from a 
chronic enteritis, though the first effect is the most 
usual. We have found the indurated state of the 
mucous membrane under the two following cir- 
cumstances : first, in cases of chronic dysentery, 
where the mucous membrane of the colon was 
hypertrophied and ulcerated ; between the ulcera- 
tions the consistence of the membrane was greatly 
increased : secondly, we have seen, in cases of 
scirrhous degeneration of the subjacent cellular 
tissue, the mucous membrane of the small intes- 
tine singularly changed ; it resisted traction re- 
markably, had lost the velvety feel, and gave to 
the touch precisely the sensation that is presented 
by the vagina in cases of advanced cancer of the 
uterus. The parts most indurated appeared to be 
the projecting edges of the valvuloe conniventes, 
and the whole of the membrane was studded with 
extremely minute and hard granulations. 

We now come to the consideration of the 
inflammatory ulcerations of the intestine. When 
we compare the bronchial and intestinal mucous 
membranes in their pathological states, we must 
be struck with the difference in the frequency of 
ulcerations in these tissues. In the first, they are 
of rare occurrence, in the latter extremely com- 
mon ; in the first we constantly see an acute or 
chronic inflammation without a trace of ulcera- 
tion, m the latter this effect constantly results 
from both these forms of disease. This difference 
may be explained by considering the great pre- 
dominance of the mucous crypts in the gastro-in- 
testinal system, as compared with the respiratory. 



ENTERITIS. 



59 



In fact, for the healthy performance of the respira- 
tory function, a very small quantity of mucous 
secretion is required, but the reverse is the case 
as to the function of digestion. We must also 
take into account the greater exposure of the di- 
gestive canal to chemical and mechanical stimula- 
tion. 

The circumscribed ulcerations of the intestine 
may be divided into two classes, those affecting 
the mucous membrane alone, and those engaging 
both this tissue and the mucous glands. The first 
of these species is the rarest ; the second is ex- 
tremely frequent, and is called the follicular ulcer- 
ation. 

As the minute description of these ulcerations 
is not of much practical importance, we shall not 
enter into the subject here, and shall merely refer 
to the late works on pathological anatomy, and to 
the article Fever, for complete information. 
Suffice it to say, that they are extremely frequent, 
and that their varieties, with respect to number, 
appearance, and accompanying disorganizations, 
are infinite. The cases in which they are most 
frequently met with are the following : — typhous 
fever, with predominance of gastric symptoms ; 
dysentery ; long-continued diarrhoea ; stricture of 
the intestine ; infantile remittent ; tabes mesente- 
ries ; tuberculous phthisis, and in cases of hyper- 
catharsis, from an over-dose of purgative medicine. 

In the great majority of cases these ulcerations 
do not perforate all the coats of the intestine, but 
in a few this does occur, and the result is most 
commonly an effusion of the contents of the in- 
testine into the peritoneal cavity, and consequent 
rapid peritonitis. Two important facts seem as- 
certained with respect to these perforating ulcers, 
Jirst, that they are almost always the result of 
disease in the mucous follicles, and, secondly, 
that they are more liable to occur from acute and 
circumscribed than from chronic and extensive 
disease. We may explain this by considering, 
that in the chronic ulcerations the cellular mem- 
brane at the base of the ulcer is generally more or 
less indurated and hypertrophied, which gives it 
an increased power of resistance to the ulcerative 
process, and also that from the general emacia- 
tion which commonly occurs in such cases, the 
tube is in a state of ancemia, where, of course, in- 
flammatory action will occur with a lesser degree 
of activity. The extent of the disease, by dimin- 
ishing its intensity in any particular point, may 
also contribute to this result. 

The situation of the perforating ulcer is remark- 
ably similar in most of these cases. In the ten 
examples recorded by Louis it occurred somewhere 
in the last twelve inches of the ileum, and out of 
the same number observed by us in the Meath 
Hospital, but one instance occurred where it was 
in a different situation, namely, the caecum. This 
ulcer was also remarkable in not presenting the 
follicular character. We may remark, that these 
observations as to the situation of the perforating 
ulcer apply principally to the acute cases. 

Effusion of the contents of the intestine is not 
a necessary result of this lesion, as the serous co- 
vering of the adjacent fold of intestine may form 
adhesions round the edges of the ulcer, and thus 
constitute its base, or a direct communication may 



be formed between two portions of the tube pre- 
viously in contact. In both these cases the oc- 
currence of general peritonitis is not a necessary 
consequence. (See the article Pehitonitis.) 

Treatment. — We shall first examine the 
treatment of the disease as it occurs in the infant 
and child. In most instances of this affection 
we may admit of two stages, indicating a different 
treatment ; the first, where the antiphlogistic me- 
thod is to be our chief resource ; the second, where 
revulsives and the cautious use of the tonic plan 
are indicated. 

In this affection it is not often necessary to 
have recourse to the lancet, although such a case 
may arise, as where the symptoms are violent, the 
fever high, and the constitution healthy and ro- 
bust : here venesection cautiously performed will 
generally be followed by the best results, and be 
the best preparative for other measures. In these 
countries a prejudice against bleeding in the child 
sometimes exists, but we believe that it is un- 
founded. More than once have we seen the 
symptoms continuing with violence, and even re- 
sisting the employment of leeches, until blood was 
taken from the arm ; then the remedies which had 
before failed acted well, and recovery was pro- 
gressive and ultimately complete. When we 
cannot succeed in opening a vein in the young 
infant, the mode from which most advantage is 
derived, is the application of a leech or two to 
the back of the hand or foot, and afterwards plung- 
ing the part into warm water ; in this way we can 
obtain a considerable quantity of blood, and the 
hemorrhage is easily controlled by a bandage. 

If the bowels should not be open, it is advisable 
to procure a moderate evacuation of the tube, but 
no violent or irritating purgStive is on any account 
to be given, and we should trust chiefly to the 
mildest laxatives and to injections, which are al- 
most always productive of the best effects. It 
sometimes happens, after the above means have 
been employed, that the disease appears either to 
be subdued or greatly lessened in its intensity ; the 
tongue cleans and the fever is much diminished ; 
but in more violent cases this alteration is scarcely 
perceptible, and then no time is to be lost in ap- 
plying leeches to the belly. This may be done at 
all ages, and is without exception our most pow- 
erful remedy in most cases. The number must 
be proportioned to the violence of the disease and 
habit of the patient. We have seen three or four 
leeches applied to the abdomen of an infant of 
twelve months old with the best effects ; but, as a 
general rule, a leech for every six months of the 
child's age up to that of four years would not be 
excessive. These may be re-applied according to 
circumstances, for it often happens that symptoms, 
scarcely if at all affected by the first application, 
will subside on the second. The prejudice against 
the use of leeches in the diseases of children is 
fast wearing away ; in fact, the only objection of 
weight is the difficulty of arresting the hemor- 
rhage. For this purpose the simplest and most 
efficacious mode is the application of the solid 
nitrate of silver to the leech-bite, A stick of 
caustic should be cut down to an extremely fine 
point, and being pressed to the bottom of the 
wound, (which should be previously dried by a 



00 



ENTERITIS. 



little lint,) and given a turn or two, is then to be 
withdrawn : this seldom fails to stop the bleeding 
at once. 

The internal remedies from which we have 
S3en most advantage are the combination of a 
mild mercurial with Dover's powder, and, in the 
next place, gummy solutions. The hydrargyrum 
cum creta, with Dover's powder, may be given in 
repeated doses, proportioned to the age of the pa- 
tient. An over-degree of narcotism is, of course, 
to be avoided ; but it frequently happens that, 
after a decided opiate effect has been produced, 
the symptoms of intestinal irritation greatly sub- 
side. It is a remedy that requires caution in its 
exhibition, but one of great utility. It sometimes 
constipates, and when this occurs it may be 
omitted, and a small quantity of castor oil or manna 
may be given, assisted by an emollient injection ; 
and when these have performed their office, the 
remedy can again be resumed. 

In some cases it may be desirable to produce a 
decided mercurial action. To excite this in the 
child is a matter of great difficulty, and our own 
experience leads us greatly to prefer the external 
application of mercurial ointment to the adminis- 
tration of much calomel. We have known a mer- 
curial plaster, or dressing a blistered surface with 
the ointment, answer remarkably well. But in 
every case we should endeavour to remove the 
disease without the exhibition of a great deal of 
mercury, as its effects in children of an unhealthy 
habit are often most formidable. 

Blisters have been used in this disease with 
various results, and if they are not employed until 
the advanced stages of the affection, and are em- 
plo3''ed only as secondary to general or local bleed- 
ing, they will often be useful. In young children 
they should never be left on for more than two or 
three hours, and in older patients they should be 
removed as soon as uneasy sensations are per- 
ceived from them. It is always advisable to insert 
a piece of silver-paper between the blister and 
skin. As a general rule, it may be stated that 
blisters should not be used when the skin is very 
hot, the fever high, and the patient in a state that 
would admit of general or local bleeding. Perhaps 
they may be more safe in those cases where the 
mucous inflammation has arisen from the suppres- 
sion of a cutaneous irritation. 

There is a difference of opinion about the utility 
of the warm-bath. We have found it chiefly useful 
in the advanced stages, and where there is much 
diarrhoea ; but it appears to us that the practice of 
diUgently fomenting the belly is as serviceable, 
and one which may be used in all stages. 

The little patient must be kept on an extremely 
strict regimen, and every thing that could possibly 
disagree must be avoided. A strict regimen is 
peculiarly necessary in the enteritis of children, as 
the slightest irregularity in this respect may pro- 
duce a fatal relapse. Cold water may be freely 
.illowed and may be slightly acidulated, according 
to the feelings of the patient ; in addition to which 
we have always been in the habit of administering 
in some quantity a solution of gum arable, and 
have seen, in cases where the disease predomi- 
nated in the lower portion of the tube, the most 
decided benefit from it. But after the first week 
of the disease it becomes necessary to attend to the 



support of the patient. Many children arc lost by 
the practitioner neglecting this point. Small quan- 
tities of the farinaceous foods, milk and water, and 
very weak chicken-broth may be used, and their 
quantity regulated by the effect on the symptoms. 
These should be given at stated intervals of time, 
say every third hour ; and it may even be neces- 
sary in the advanced stages to administer a little 
wine, particularly when the skin is cool, the coun- 
tenance sunk, the mouth covered vvitl" sordes, and 
the stools involuntary. Should this excite a too 
strong re-action, it can be omitted, and again re- 
sorted to if necessary. Great attention must be 
paid throughout to prevent excoriation of the back, 
and to preserve the warmth of the extremities, and 
the apartment should be kept at a regulated tem- 
perature. This, among its other advantages, will 
tend to prevent the liability to bronchitis, which 
disease sometimes carries off the patient after the 
subsidence of the enteritis. 

Enteritis in children is commonly mistaken for 
worms, and thus improperly treated. Drastic 
purgatives are lavished ; the increase of symptoms 
and the marasmus are attributed to the persistence 
of the worms ; until at length typhoid symptoms 
appear, or the child falls into the state of tabes 
mesenterica. These cases are always of the worst 
description from obvious reasons. It would appear 
that when the disease arises from the use of indi- 
gestible food, or from constipation, purgatives 
cautiously exhibited at the outset are useful ; but 
if after the unloading of the bowels the symptoms 
continue, it is a sign that something more than 
mere irritation from the presence of noxious sub- 
stances exists, and that we must treat the disease 
as one of enteritis. These remarks apply equally 
to the enteritis of the child and adult. The indis- 
criminate system of purging in all cases is the 
opprobrium of British medicine ; for it is a fact 
that, since the writings of Hamilton and Aber- 
nethy, too many practitioners have had, in the 
treatment of digestive derangements of most kinds, 
but two objects in view, the one, of giving doses 
of purgative medicine, the other, the quantity and 
quality of the fa;cal discharges ; while the gastro- 
intestinal surface, that prodigious vasculo-nervous 
expansion, has been wholly unheeded and for- 
gotten. 

Cerebral symptoms often supervene in the course 
of this affection, and it is sometimes difficult to 
say whether they proceed from actual disease of 
the brain, or merely indicate a sympathetic excite- 
ment not amounting to positive inflammation. 
But we know that sympathetic irritation cannot 
long exist in so delicate an organ as the brain 
without producing disease, and further, that we 
cannot tell when this change takes place. Hence 
the safe mode of proceeding is always to treat the 
cerebral symptoms as if they really proceeded from 
encephalitis. In such a case it is generally unne- 
cessary to use the same degree of vigour in treat 
ment as if the disease was idiopathic inflamma- 
tion. 

When the disease occurs in the adtilf, the chief 
remedy will be found to consist in the detraction 
of blood generally and locally, but particularly 
the latter, unless in cases where the symptoms 
run high and threaten peritoneal inflammation. 
Here the lancet is ne\er to be neglected, and 



ENTERITIS. 



61 



its use must be repeated frequently if the vio- 
lence of the disease is not subdued. Dr. Aber- 
crombie recommends the practice of following up 
«.!ie first bleeding by smaller detractions of blood, 
so as to keep up a decided impression on the sys- 
tem. It seems, however, that in most cases we 
may look on general more as a preparative for 
local bleeding, which, when properly performed, 
is a means of extraordinary value. Facts, how- 
ever, oblige us to admit the efficacy of general 
bleeding alone in reducing inflammations of the 
mucous membrane. (See Cheyne's Report on 
Dysentery.) When the disease exists in the 
small intestine, we have always found most ad- 
vantage from local bleeding. It may be performed 
at various stages of the disease, even when there 
is great adynamia, and will seldom disappoint the 
practitioner. Leeches should be applied abun- 
dantly round the navel or to the ileo-caecal region, 
and the hip-bath used when they fall off. If the 
symptoms do not yield at once to this treatment, 
the leeching is to be boldly repeated, and a large 
poultice applied over the belly. The bowels are 
to be gently opened by the mildest laxatives, and 
emollient injections should be frequently given. 

The most distressing symptoms in this disease 
are the vomiting, thirst, tympanitis, and diarrhoea. 
It is often very difficult to allay the first of these. 
We have found nothing so efficacious as the ap- 
plication of a dozen leeches to the epigastrium, 
and the liberal use of iced water, or even plain 
ice, which may be given nearly ad libitum. It is 
a most grateful and important remedy, and one 
from which we have never seen any unpleasant 
results. In the more advanced stages of the dis- 
ease we have constantly appHed leeches to the 
epigastrium, though in a smaller number, and 
have seen that assemblage of phenomena which 
constitute the typhoid state speedily disappear 
after their use. In addition to this, we have in 
the hospital often applied a small blister over the 
region of the stomach, and afterwards sprinkled 
the surface with a little acetate of morphia, a 
practice which, in some cases, succeeded remark- 
ably. Effervescing draughts, with the carbonate 
of soda or ammonia, may be exhibited, but not in 
too great quantity, as violent diarrhoea and exas- 
peration of all the symptoms may be the result of 
this excess. Lastly, opiates, and, in some very 
advanced and low cases, stimulants may be used 
with advantage. The thirst may be moderated 
by the use of cold acidulated drinks, such as 
lemonade, the cream of tartar solution, and tama- 
rind-tea; but let it never be forgotten that the 
means best calculated to remove these symptoms 
are those calculated to reduce the inflammatory 
action. The tympanitis, when it arises, is a 
symptom commonly maltreated from ignorance of 
its pathology. Occurring in the early stages of 
the disease, it is generally in proportion to the in- 
tensity of the inflammation. It is a distressing 
symptom, and hence practitioners are over-anxious 
for its removal, and are tempted to exhibit turpen- 
tine. From witnessing a great number of cases 
where this practice has been pursued, we feel 
certain that the exhibition of turpentine or analo- 
gous remedies for the removal of tympanitis in 
the early stage is a practice pregnant with danger. 
ft often, indeed, renders the belly flat ; but this 



apparent advantage is commonly followed by an 
increase of the other symptoms ; and the tympa- 
nitis is sure to return. If the symptom be not 
severe, its presence should not make us modify 
our treatment ; if it is excessive, it becomes a 
sign for increased activity in means calculated to 
reduce the inflammation without endangering the 
safety of the patient. In addition to this, stimu- 
lating injections, where there is not tenesmus, 
may be used, and enemata of cold water in all 
cases. In the stages of the disease, however, 
where depletion can no longer be practised, the 
use of turpentine is sometimes successful, a cir- 
cumstance reconcileable with our knowledge of 
the effects of stimuli in the advanced periods of 
mucous inflammation. 

Nearly the same remarks apply to the diarrhoea. 
The exhibition of astringents in the early stages 
is generally followed by the worst effects, a cir- 
cumstance favouring the doctrine that the secre- 
tion is the relief of the inflammation ; but when 
the powers of life are low, and the disease not 
acute, we must moderate it. This is best done by 
the warm bath, a flannel roller, the occasional ap- 
plication of a blister to the belly, anodyne injec- 
tions, and the use of small doses of Dover's pow- 
ders, with or without rhubarb. Where the diar- 
rhoea was severe and the patient much depressed, 
we have often used large doses of opium with the 
best effect. 

The remarks as to revulsion, regimen, &c. 
which we made in treating of the enteritis of 
children, apply equally in this form of the dis- 
ease. 

[The treatment adapted for inflammation of 
the csecum. is that of local inflammation in gene- 
ral. General blood-letting may be required, but it 
cannot be nscessary to repeat it often. The great 
indication is, to temper the inflammation as far as 
possible, and especially to remove the cause, where 
the disease is owing to hardened excrement, or to 
any undigested matter, — as stones of fruit, char- 
coal, magnesia, &c., which are sometimes known 
to lodge in the caecum. 

Simple typhlitis of the mucous membrane re- 
quires the same treatment as colitis ; and peri- 
typhlitis the same management as any case of 
partial inflammation of the cellular or serous mem- 
branes. 

In cases of inflammation of the csecum from 
mechanical causes — typhlitis stercoralis — after 
general blood-letting has been practised, leeches 
may be repeatedly applied ; the practitioner bear- 
ing in mind, however, that if he be unable to pre- 
vent the supervention of suppuration, he may do 
mischief by reducing the powers too much. After 
the leeches have dropped off, a large warm poul- 
tice may be applied, or if this cannot be borne, a 
hot and dry fomentation of chamomile flowers in 
a flannel bag. The most important fomentation 
is warm water sent copiously into the colon, which 
may be thrown in by means of one of Dr. 
O'Beirne's rectal tubes. In this manner, the im- 
pediment may be removed. If repeated glystery 
be unable to accomplish this, cathartics — as oleum 
ricini, or infusion of senna with salts — may be 
administered, in addition, by the mouth. 

It can rarely be necessary to have recourse to 
more powerful remedies than these, repeated every 



62 



ENTERITIS — EPHE LIS 



two hours until an evacuation takes place, and 
aided by the eneniata recommended above, or with 
the addition of castor oil. The hot bath has been 
proposed, but it possesses no advantage over hot 
fomentations, whilst the motion, to which the pa- 
tient's body is necessarily sutijected, renders it ob- 
jectionable. In the course of a few days, the 
bowels may begin to be evacuated, and lumps of 
undigested matter — the cause of the whole mis- 
chief — may be perceptible in the discharges. 

If signs of suppuration occur, poultices may 
be applied ; and if there be reason to believe that 
the parietes of the abscess adhere to the walls of 
the abdomen, which may be determined by trying 
whether the latter glide over the tumour, the 
sooner the abscess is opened the better. Com- 
monly, the tumour gives an emphysematous feel, 
and if a free incision be made into it, a fetid gas 
with an offensive fluid will be discharged. — 
This emphysematous condition must be distin- 
guished from the sound rendered on percussion, 
when the pus has formed on the posterior surface 
of the caecum, and pushed the intestine before it. 
In such case, the intestine may be wounded, as 
has happened, we are told by Grisolle, in one 
case. After the abscess has been opened, the dis- 
charge of its contents must be favoured by placing 
the patient on his right side, and the system be 
supported by wine-whey ; arrow-root, or sago and 
wine ; beef tea, and the preparations of bark. Opi- 
ates will likewise be required to produce sleep. 

Where the perforation takes place into the ca- 
vity of the peritoneum, the case must be managed 
as directed under the head of Perforation of the 
Intestines. Little, however, can be done except 
to administer full doses of opiates. 

Lastly, — where the abscess is so deeply seated, 
that an opening into it cannot be made with safe- 
ty, it has been proposed to endeavour to promote 
the absorption of the pus by means of repeated 
blisters, or by moxa applied over the abscess. 

The treatment of inflammation of the appen- 
dix vermiformis cxci is the same as in perforative 
inflammation of the caecum. As in all cases of 
inflammation likely to terminate in extensive sup- 
puration, in which the recuperative powers have 
to be greatly exerted, care must be taken not to 
reduce too much by general blood-letting, too 
often, or too largely practised in the early stages. 
Every practitioner is aware of the difficulty of 
arresting the suppurative process ; and, conse- 
quently, if the inflammation be not got under by 
antiphlogistics in the first few days of the disease, 
the farther use of depletives should be had re- 
course to, under a wise caution ; for it is proper 
to remark, that the disease occurs at times very 
insidiously. 

The treatment of sero-colitis is the same as re- 
commended in acute and chronic inflammation of 
the peritoneal coat of the small intestines, and in 
inflammation of the caecum.] 

W. Stokes. 

[ROBLEY DUNGLISON.] 

[ENTEKORRHCEA. (See DiAHRHtEA.)] 

EPHELIS (from hi and 17X105, sol,) a genus 

■of diseases of the skin, of the order macitlx, (see 

the article Macul.^,) characterized by discolora- 

lions, varying from dark brown to greyish-yellow, 



and presenting a great diversity of form, from 
small distinct points, sometimes scattered, some- 
times grouped, to large confluent or continuous 
patches. 

Si/n. Macula? fuses (Plenck) ; Ephehdes {Ali- 

beri). 

We use the term ephelis in the extensive sense 
which has been given to it by Gorroeus — " non 
quod a sole tantum vitia ilia in cute contrahuntur, 
sed quod a reliquis inducta causis, similcm aspe- 
ritatem et colorem habeant ;" (Defin. Med. ad voc. 
l^ri\iv,) although we do not altogether agree with 
Bateman, (Synopsis, p. 442,) that this acceptation 
of the term is sanctioned by the authority of Hip- 
pocrates, (Prcedict. lib. 2. xxxi. 9 ; de aUmento, 
iv. 11 ; de sterilibus,vi. 8 ; de morb. mulier. lib. 2, 
Ixvii. 6, Ixviii. 1,) for he appears to have distin- 
guished between lenticula ((paKbi) and ephelis, 
both included in this definition. Celsus went far- 
ther; he not only distinguished between lenticula 
and ephelis, but also between lenticula and the 
0a/c/a of the Greeks. (De Medicina, lib. vi. cap. 5.) 
These distinctions were lost sight of, and the term 
ephelis was made more comprehensive by Oriba- 
sius, (De loc. affect, cur. lib. iv. cap. 52 ; Synops. 
viii. 33,) .^tius, (Tetr. ii. serm. iv. cap. 11,) and 
Actu^rius. (Meth. Med. iv. cap. 13.) Senner- 
tus (De cutis vitiis, lib. v. pars 3,) revived the an- 
cient distinctions, in which course he was followed, 
more or less, by Sauvages, Lorry, and Plenck; 
but whilst the first of these raised distinctions on 
one hand, he removed them on the other, and 
thus included under ephelis morbid appearances 
which have no relation to it. This last is also the 
error of Alibert, who, in his order of Ephelides, 
includes scorbutic blotches. 

These affections of the skin seldom demand or 
deserve, on their own account, the attention of the 
practical physician ; but as signs of internal disor- 
ders they sometimes afford very valuable diagnos- 
tic evidence, as much as erysipelas, urticaria, pru- 
rigo, and many other eruptions. And we perfectly 
agree with Alibert, that they afford matter of in- 
teresting research to the physiologist, showing how 
the integuments may become discoloured, and re- 
vealing in some manner, by external appearance, 
the alterations to which the human body is sub- 
ject. Besides, it is shown in the study of the 
natural sciences that the most trifling facts may 
be useful, because, being connected by an almost 
imperceptible chain with phenomena much more 
important, they sometimes indicate, sometimes ex- 
plain them. 

The process of the formation of the ephelis is 
unknown. It is not the result of any particular 
alteration of the epidermis, but some modification 
of the pigmentum of the skin which science is not 
yet able to explain. It would seem sometimes to 
be a consequence of an inflammatory action ; it is 
frequently accompanied with signs of a determi- 
nation of blood to the skin, but neither of them 
is constantly observed. It is very variable in its 
progress and duration, sometimes developing itself 
fully and extensively in the course of a night, 
sometimes very slowly; sometimes it is perma- 
nent, continuing indelible for several years, and 
sometimes it disappears after a single bath or lotion. 

Not having found any previous arrangement 
of this genus which sati'sfactorily comprehends all 



EPHELIS, 



G3 



its varieties, we propose considering it under two ' some relation to the complexion and colour of the 
species, viz. I. E^heVis lentigo,- 2. Ephelis diffusa. 
1. Kphclis lentigot Si/n. ^a/cis (^Hipp. et 
Grace.) ; Lenticula vel lentigo (La/m); Ephelis 
lentigo (Sauvi/ges and Alibert); Lentigo (Lorry, 
Plenck) ; Lentigo ephelis (^Frank) ; Sommers- 
prossen et Sonncnsprossen, Sommerflecken ( Teu- 
'onice). Freckles. 

An eruption of small minute spots of a fawn, 
yellow or brown colour, sometimes disseminated, 
sometimes in clusters, unaccompanied with any 
pain or itching. 

This eruption presents itself under two circum- 
stances ; it is either hereditary, a natural deformity 
of the skin, or is purely accidental, the result of 
exposure to the sun's rays. This affords the di- 
vision of the species into two varieties: a. Ephelis 
lentigo niuierna. h. Ephelis lentigo aestiva. 

a. Ephelis lentigo materna. Taches de rous- 
seur (Gallice). The well-known lenticular erup- 
tion, forming, as it were, part of the natural com- 
plexion of yellowish or reddish-haired persons, 
who are, besides, distinguished by the strong odour 
exhaled by the secretions of their skin. (Alibert, 
PI. xxvi.) It is more rarely, but sometimes, ob- 
served in persons of a fair and delicate skin with 
dark hair and eyes. The colour and shade of the 
eruption bear always a near relation to the colour 
and shade of the hair, being sometimes as dark as 
coftee 01' chocolate, and sometimes of a light yel- 
low. The eruption is not confined to the parts 
of the body exposed to the light and air, but some- 



hair. 

When this eruption does not cease with tho 
removal of its cause, or with seclusion, or the use 
of veils or shadowing hats, its disappearance may 
be accelerated by the use of certain local applica 
tions ; and, indeed, even under the influence of 
its cause, it may be much moderated by them. 
Every country supplies some of these nostrums, 
chiefly domestic, the results of vulgar experience. 
They are most of them more or less stimulating, 
but some of them soothing and demulcent. The 
best practice is for the bland and emollient appli- 
cation to precede that of the stimulating. The 
former consists of such things as vapour (that of 
milk was an especial favourite) ; emulsion of the 
seeds of cucumbers or melons, or pomatum pre- 
pared from those seeds ; decoction of the flour of 
lupines, of tares ; the boiled pulp of the roots of 
narcissus ; paste of bitter almonds, and such hke. 
The latter consisted of poultices made of the seeds 
of cauliflower, or of the flour of tares or lupines 
macerated in vinegar, or the bulbs of the narcis- 
sus boiled in vinegar, to which was added some 
of the roots of the wild cucumber, bryony, and 
the leaf-stalks of the fig-tree ; the juice of tho 
house-leek, the leaves of the cherry-tree, the leaves 
of ivy, the ashes of sepia, the bulb of the Illyrian 
iris, and the bulbs of the lily, mixed with nitre 
and honey. Ox-gall has been always celebrated. 
The favourite remedy in the harem of Turkey is 
said to be a pomatum prepared from balsam of 



times occupies the whole surface ; neither does it Mecca, the seeds of the garden cucumber and 



disappear in winter. It is to this variety that the 
French term, " taches de rousseur," strictly applies. 

They who would attempt to cure this deformity 
would deserve a severer rebuke than that of Cel- 
sus — Pene ineptix sunt, curare varos, et lenti- 
culas, et ephelidas. But the importance attached 
by the fair sex to this discoloration has not left 
the matter unattempted — eripi tamcn faeminis 
cura cultus sui non potest. It would be idle to 
repeat the various means which have been used 
for this purpose. They who are curious in such 
matters may consult ^tius, lib. 1. serm. 4. cap. 
ii. ; lib. 4. cap. xiii. ; Haly Abbas, lib. 9 ; Avi- 
cenna. Fen. 7. tr. 2 ; or the monograph of Bender 
on Cosmetics. (Phil. Ludov. Bender de Cosmet. 
Argent. 1764.) 

b. Ephelis lentigo aestiva. — Syn. Ephelis : ma- 
culae solares (Plenck) ; Ephelis a sole (Sauvages) ; 
Nigredo a sole (Sennert) ; lentigo sestiva (Jos. 
Frank) ; Le hale {Gallicee). Sun-burn. 

To this variety exclusively belongs that very 
common lenticular eruption, chiefly observed in 
young females of a delicate complexion, superven- 
ing with the summer and disappearing with the 
winter, and confined to those parts of the body 
exposed to the sun and air. 

This eruption is purely a local affection ; the 
radiation of the sun upon the exposed surface of 
the skin, more particularly observed in youth, 
being the only cause of this eruption; hence 
those occupied in the labours of the field, moun 



cerussa : in the north of Europe, Goulard's lotion, 
the juice of sorrel, lac sulphuris macerated in tho 
juice of currants, solution of sulphates of zinc or 
copper, lemon-juice, oxycrate with camphorated 
mixtures, rubbing the part with a slice of lemon 
or of a sour apple. But all these various means 
may be more conveniently represented by any 
weak alkaline solution, 

(B. Liquor, potassae, ^i. 

Aq. rosar. ^ii. fiat lotio.) 
or a diluted spirit or acid lotion. 

The following were favourite formulse much 
vaunted : 

R 01. amygdal. amar. ^i. 
Tartar, per deliquium, ^ss. 
01. rhod. gtt. ii. M. 
R Sapon. venet. ^ii. solve in 
succ. limonis, ^i. adde ol. 
amygdal. amar. Tartar, per 
deliquium, aa. ^ss. 
01. rhodan. gtt. vi. M. fiat poma- 
tum part, illin. 

2. Ephelis diffnsa, an eruption of distinct or 
confluent large, irregular, round patches, of a 
tawny, yellow, or brown colour. 

This form of ephelis may be symptomatic as 
well as idiopathic. 

a. Ephelis diffusa symptomatica. — Syn. Ma- 
culae hepaticae (Sennert, lib. 3, pars iii. sect. i. 
cap. viii.) ; Hepatizon ( Var. Auct.) ; vitiligo he- 
patica (Sauvages) ; kelis fulvescens (Swediaur) • 



taineers, those accustomed to expose themselves Ephelis (P/e7ic/<-) ; Chloasma (^P. and J. Frank) ; 



bareheaded, or persons pent up and etiolated in 
cities, when they visit the country are particularly 
subject to it. This cause may operate quickly or 
slowly, and the colour of the freckle always bears 



Ephelis hepatica (Alibert) ; chaleur du foyc, 
taches hepatiques ( Galilee) ; Leberflecke ( Teu - 
toniee). 

This eruption, which is generally precedc4 by 



04. 



EPHELIS — EPIDEMICS. 



at slight itching, is of the colour of saffron or rhu- 
barb, sometimes pale like the withered leaf; it is 
most commonly situated on the neck, sometimes 
surrounding it like a cravat ; on the abdomen, 
especially on the region of the liver, over the kid- 
neys, or on the groins ; sometimes on the fore- 
head. The patches are at first distinct and dis- 
tant, but extending gradually they run into each 
other, or they form groups more or less numerous. 
(Plate LXix. Bateman's Delineations; Plate 
xxTii. Alibcrt.) They are sometimes slightly 
elevated, and terminated by a desquamation of 
fine thin yellow scales assuming somewhat of the 
nature of pityriasis, the pityriasis versicolor of 
Willan, the chloasma pseudo-porrigo of Frank ; 
and sometimes they are complicated and coinci- 
dent with the wheals of urticaria. The itching 
is sometimes much greater than that of pityriasis ; 
it is much influenced by the weather, and increas- 
ed by being heated by exercise. Alibert has ob- 
served that the patches of ephelis are not trans- 
pirable, but very dry, whilst the surrounding skin 
is soft and moist. 

This variety of ephelis is sometimes permanent 
and sometimes transient. In the first state it is 
met with chiefly in men of close sedentary habits, 
presenting large blotches upon the alJdomen, some- 
times entirely encompassing it as a belt, or large 
patches over the shoulder. Some of these spots 
it is not difficult to disperse, but some remain in- 
delible. In the second state they are more fre- 
quently observed in women in the form of isolat- 
ed circular patches, appearing and disappearing 
very rapidly, sometimes in the course of half a 
day ; they are chiefly seated on the back part of 
the neck, on the throat, breast, and hypochondria. 
In some women they return at every menstrual 
period ; in others they coexist with suppression 
of the catamenia, the chloasma amenorrhoeum of 
Frank ; they afford sometimes a sign of concep- 
tion, (^Hippoc. de morbis mulier. Sennert. Pract. 
lib. .5, parts iii. s. 1, c. 2,) appearing as superficial 
spots as broad as the hand, of a pale yellow or 
dark tawny colour, without roughness or inequal- 
ity, most frequently on the forehead, breasts, and 
abdomen, occasionally disappearing at the end of 
the first month, but frequently continuing during 
the whole period of gestation, and not always dis- 
appearing on parturition — the ephelis gravidarum 
of Plenck and Sauvages, the chloasma gravida- 
rum of Frank. It is remarked that those who 
arc most indisposed by pregnancy are most liable 
to this eruption. In men they are observed some- 
limes precursive of a hemorrhoidal flux. In wo- 
men, the itching attendant upon them is always 
increased on the approach of the menstrual period. 
Sauvages says he has not unfrequently observed 
the eruption of ephelis to be periodical after ter- 
tian and quartan agues, and sometimes an attend- 
ant of nostalgia. 

Besides the state of body just mentioned as 
predisposing to this variety of ephelis, it is fre- 
quently accompanied by a serious disorder of the 
function of the fiver, but most constantly con- 
nected w4tli chronic irritation of the stomach and 
intestines. In such cases it is sometimes suddenly 
excited by any trifling vexation, chagrin, or con- 
trariety, or by protracted application or studv. 
The treatment of this eruption consists in the 



appropriate cure of the primary disorder of which 
it may be a symptom : when connected with the 
natural functions of the body, it can only be 
remedied by promoting their more easy perform- 
ance ; when symptomatic of uterine disorder, it 
demands the treatment of amcnorrhoea or dysme- 
norrhoja, when of chylopoietic disorder, its cure 
falls under dyspepsia. In general, mild cooling 
cathartics, light diet, sulphurous preparations, par- 
ticularly the sulphurous mineral waters, as those 
of Harrowgate, Cautcrets, &c., and, if necessary, 
a mild alterative of some mercurial and antimonial 
preparation, constitute the internal remedies. The 
best external preparations are sulphurous baths, 
particularly of the natural warm mineral waters, 
the warm sea-bath, or locally a lotion of sulphuret 
of potass. 

R Potass sulphuret. ^i. 
AquiB lib. ii. fiat lotio. 
Camphorated vinegar is also a good local applica- 
tion. When the spots are indolent, friction, and, 
if not extensive, a sinapism applied for a short 
time, or a poultice of soft soap, have been known 
to succeed. 

b. Ephelis diffusa idiopathica. 

We only notice this variety that we may not 
omit two forms of ephelis enumerated by other 
writers. 

1. Ephelis ignealis (Sauvages) ; ephelis spuria 
(P. Frank) -, lentigo ab igne (J. Frank) ; tiiches 
de brulure (^Galilee). The mottled spots pro- 
duced by artificial light and heat, observed on the 
legs and arms of those who bask over the fire, oi 
on the legs and thighs of women who during 
winter make use of the chauffepie. 

2. Nigredo a sole (^Sennert ) ,- fuscedo cutis 
(^Plenck) ; ephelis umbrosa (Ji Frank) ; die 
braune haut [Teiitonice) . The dark, swarthy, 
brown colour of the skin acquired by Europeans 
who inhabit tropical climates, or by those exposed 
to salt water and hard weather. 

T. J. Todd. 

EPIDEMICS. Epidemic diseases (viJo-oi iml- 
finoi, from i»ri, among, and ^^/^oj, people,) are those 
which attack a number of persons, in any city, 
district, or country, about the same time or season. 
They are generally uncertain in their recurrence. 
When they produce great mortality they are called 
pestilentiaL Epidemic diseases are chiefly of the 
acute or febrile class, some of which are apt to 
prevail in spring, some in summer, and some in 
autumn ; some in one country, and some in 
another. 

Endemic diseases are found to prevail more or 
less at all times, in districts where the local causes 
act, and among people exposed to their operation: 
but the production of epidemics, inasmuch as they 
depend on circumstances of a wider range, which 
are in their nature variable, (such as the vicissi- 
tudes of heat and cold, the prevalence of particu- 
lar winds, the varieties of season and weather, as 
to drought and moisture, the deficiency or deterio- 
rated quality of different articles of common 
food, and other things, is liable to great uncer- 
tainty in almost every part of the world. 

As epidemic diseases are above defined they 
do not exclude some that are contagions ' Dis- 
tinctions have been attempted to be established it 



EPIDEMICS. 



65 



would appear unwisely, between epidemic and 
contagious diseases. An attentive and unbiassed 
observation of facts removes these unphilosophical 
distinctions. Many epidemic diseases appear, 
under certain circumstances, to be communicable 
by contagion ; and some diseases, avowedly con- 
tagious, prevail epidemically. Facts, in all ages, 
would seem to show that most epidemic diseases 
have a tendency to spread by intercourse with 
those exposed to the same causes of disease, and 
thus predisposed to it. This tendency has been 
made too much of by systematic writers, in some 
cases ; and in other cases, too little. No epidemic 
disease either attacks simultaneously, or rages 
with indiscriminate violence, among all classes, in 
any community ; and no contagious disease 
attacks every one who is fully exposed to its 
influence. Epidemic diseases, whether contagious 
or not, have their assigned laws. Even when 
highly pestilential and destructive, they observe 
stated seasons, and periods of rise, increase, and 
decline. When their attack is most sudden and 
general, they pass over a large proportion of the 
community. In the former case the disease loses 
its malignity ; in the latter, some constitutions are 
proof against the common destroyer, without any 
apparent immediate intervention of art. 

It is a rare thing that any one form of epidemic 
disease rages alone, that is, without being preceded 
or followed by another. Different forms of epi- 
demic diseases usually succeed each other in a 
series, either in the same year or in different 
years : and this is called an epidemic constitution. 
Sydenham was, of all English physicians, the 
chief observer of these phenomena, and was pre- 
eminently entitled to the appellation of the English 
Hippocrates : he was of too honest a nature to let 
preconceived opinions and mere arbitrary names 
of diseases prejudice his correct observation of 
their changes from one season to another. 

Viewed practically, epidemic diseases require 
minute and cautious observation on the part of 
the physician ; for diseases of the same name, as 
Sydenham remarked, often require different treat- 
ment at the beginning of the epidemic and at the 
decline ; as they require different treatment in dif- 
ferent countries, and frequently in the same, under 
different epidemic constitutions. The diseases of 
an epidemic constitution will sometimes show an 
unusual tendency to one part of the system, and 
sometimes to another ; as they will afiect a parti- 
cular type. This tendency is either to the skin, 
or the head, or the chest, or the stomach and 
bowels, and often continues for many months, or 
even years, in the reigning diseases. It was re- 
marked that at the time the sweating sickness 
raged in England, other diseases assumed the 
sweating tendency. 

It is much to be lamented that many things 
stand in the way of accurate knowledge on this 
subject. It is comprehensive, and surrounded 
with difficulties, in proportion to the extent and 
variety of the observations which are requisite for 
forming scientific conclusions. If medical ob- 
servers had been contented to look with simplicity 
into the series of events belonging to epiacrnib 
diseases, like Hippocrates and Sydenhaiii, we 
should not have been so much in the dark at the 
present day. Facts apparently contradictory, at 

Vol. II — 9 » • 



least as to the proper name and the contagious 
quality of certain epidemic diseases, such as the 
Levant plague, the Asiatic cholera, and the yellow 
fever, have been brought forward by men justly 
eminent in their profession, but wedded to parti- 
cular opinions. Hence has arisen the extreme 
difiiculty of knowing the truth. Physicians, on 
the very site of pestilence, have sometimes, like 
children at play, taken opposite sides, and main- 
tained their ground with unseendy pertinacity ; 
so that we may look in vain to either party for 
unprejudiced observations. The records of all 
modern visitations of pestilential epidemics pre- 
sent us with opinions and statements as much at 
variance as light and darkness ; and hence we 
must conclude either that one set of observers are 
right and the other wrong, or both partially in- 
formed but blinded by prejudice, so that they can- 
not see any truth in their antagonists' assertions ; 
consequently, that many things which they report 
as facts are only partial observations, or vague 
rumours, or hastily formed conjectures, or uncon- 
nected and adventitious appearances. Truth is 
sacred, and error cannot be propagated without 
some injury. How incumbent, then, is the duty 
of medical observers to inquire impartially and to 
report with fidelity! He that presents us with a 
physical observation clouded by his prejudices, on 
a subject so deeply important to the health and 
welfare of his fellow-creatures, is but a degree less 
culpable than the man who gives a false colouring 
to some moral or religious truth, which involves 
the dearest interests of humanity. 

If this view be correct, where shall we look for 
the facts — strictly such — which may assist our 
reasonings on this weighty subject ? It is not, 
clearly, to recorded observations of infection and 
of non-infection, adduced by contagionists and 
their opponents, that we must refer ibr those un- 
exceptionable data on which some safe practical 
conclusions may be built. We may perhaps ad- 
mit something from each, but must reasonably 
doubt their wholesale inferences. 

The subject would be involved in a cloud of 
darkness which no diligent and honest inquiry 
could penetrate, if there were not other things be- 
sides facts of infection and non-infection — in 
short, other facts connected with the origin, spread, 
and decline of pestilential epidemics, (for to these 
we shall chiefly confine our attention in the pre- 
sent article) — which, though too much overlooked, 
throw a good deal of light upon the whole ques- 
tion, and not only point to something quite inde- 
pendent of their contagious and non-contagious 
nature, but help us to determine how much im- 
portance we should attach to these circumstances 
in the general estimate. It is fortunate for our 
science that there is such a class of facts, and that 
the lover of truth has not to range in a wilderness 
of uncertainty. It is also a source of gratification 
that many of these facts are admitted by both 
parties, or at least, with few exceptions, aie not 
denied by either. 

Wow, me tacts of a comprehensive nature above 
t'.iuded to, wnicn belong to pestilential epidemics, 
may be classed under the following heads ; on 
each of which it is proposed to make a few gene- 
ral observations, with a view ^f drawing "siiw* 
conclusions from the whole. 



6G 



EPIDEMICS. 



1. The natural signs, which arc either the an- 
tece{lcnt indications or the concomitants of a pes- 
tilential epidemic, such as intemperate seasons 
and unusual weather, deficient or unwholesome 
food, mortality among any species of the lower 
animals, uncommon abundance of some of the 
insect and reptile tribes, departure of birds, &c. 

2. The singular changes which have been ob- 
served to occur in the common or reigning dis- 
eases of the place, before, during, and after an 
epidemic pestilence. 

3. The changes in the symptoms, or type and 
character of the epidemic pestilence itself, and the 
circumstances attending its migrations from one 
place to another. 

4. The facts relating to the connection of epi- 
demic pestilence with offensive cities, marshy 
grounds, and low filthy situations, bad food, and 
a condensed, filthy, and ill-fed population, in all 
countries ; and, on the other hand, the exemption 
of those places where due attention has been given 
to cleanliness, wholesome and sufficient food, and 
a rational sj'stem of health police. 

5. The facts given in evidence from quarantine 
establishments and lazarettos. 

Before we proceed further, it is proper to ex- 
plain what is meant by an epidemic pestilence : the 
term is used genericaily to include several species. 
It denotes a destructive or fatal disease, which ap- 
pears at uncertain periods or intervals, but at sea- 
sons of the year peculiar to different epidemics 
and to difTerent countries, in large assemblages of 
human beings, already predisposed to receive it: 
it attacks its victims in succession with various 
degrees of violence, leaving however man}' un- 
touched, during the course of a few weeks or 
months, in a particular place or city, and then de- 
clines by degrees, as it began, but with diminished 
force, either moving onwards to other places which 
it invades in the same manner, or entirely disap- 
pearing for the lime. 

The plague of Egypt and the Levant, the bilious 
fever of Spain, and the yellow fever of America, 
the cholera of India, and the low malignant fever 
of our own country, are different forms of pesti- 
lence, observed sometimes to prevail epidemically 
in their respective countries ; for different coun- 
tries seem to have their particular forms of epi- 
demic ppstilence to which they are more liable 
than to others, and which, in common experience 
at least, do not invade each country indiscrimi- 
nately. When individual cases of any of these 
forms of disease occur :•? unusual seasons, or at 
times when there is no tendency in the disease to 
spread ; in other words, when there appears to be 
no predisposition in the population of any city or 
town to receive it, the disease is said to be spora- 
dic or local : such cases may appear at any time 
in the country which gives birth to the disease. 
If such sporadic or local cases should by any 
•;hance appear in other countries, by whatever 
means occasioned or introduced, a multitude of 
facts seem to demonstrate that there is no danger 
of their spreading, at least to any alarming extent. 
I. It is stated, by Dr. Mead in his learned Trea- 
tise on the Plague, (Chap, i.) that a "corrupted 
state of air attends all plagues." Dr. Mead was 
Hti enliirhtened physician, and though his work 
fas written professedly to establish the contagious 



nature of the disease, yet his researches into v^c 
histories of the various visitations of pcst.lence in 
different countries compelled him to admit that ":i 
corrupted state of air is, without doubt necessary 
to -ive the contagious atoms their full force. Dr 
Russell, who practised at Aleppo during the plague 
of 1760-1-2, admits in its fullest extent the dogma 
of Mead but expresses the fact in other terms, 
more philosophically perhaps; and denominates 
that state of air which is alone f\ivourable to the 
propagation of disease, a pestilential cnnstituiwn 
of the air ; without which, he states, " it is incon- 
testable that the plague will not become epide- 
mical." It must not be forgotten that Dr. Russell 
was a warm advocate for the foreign origin of pes- 
tilential contagion; and that he maintained no 
combination of indigenous circumstances could 
give rise to the plague in Syria. Sydenham, also, 
who witnessed the rise of the plague in London 
in 166.5, found it necessary to take a "pestilential 
constitution of the air" for granted. (Chap. ii. 
sect, ii.) Here, then, is an ultimate fact, so far 
as the testimony of such eminent physicians can 
establish it — a principle on which to found an 
argument as clearly laid down as any other in 
natural history. We might not be disposed to 
contend either for the propriety of the terms used 
by Mead, or for the absolute correctness of those 
emploved by Sydenham and Russell ; but for a 
slate of air, present or just past, and perhaps also 
of the body, indispensable to the epidemic rage of 
pestilential fever. 

It is a fact too well known to be questioned, 
that plagues and pestilential fevers, whether the 
bilious yellow fever or malignant typhus, have of- 
ten been preceded and accompanied by irregular 
and intemperate seasons ; in other words, by great 
extremes in the weather. If we examine the his- 
tories of the plagues of London in 1625 and 166.5, 
of the Netherlands in 1635-6, of Aleppo in 1740 
and 1761, of Marseilles in 1720, and of Malta in 
1813; if we turn our eyes to the modern visita- 
tions of pestilence in Spain and the United States, 
and the East Indies; or if we look back to the de- 
scriptions of the plagues of Athens and Rome, as 
recorded by Thucydides and Livj', without laying 
any stress on the poetic colouring of Homer, Lu- 
cretius, and Ovid, we find that some remarkable 
intemperature of the weather and seasons has been 
the antecedent, and, generally, a warm southerly 
constitution of the air a concomitant of these 
events. This intemperature, whether marked by 
excessive cold followed by excessive heat, or ex- 
cessive rains followed by excessive drought, and 
vice versa, has so often concurred with fatal epi- 
demical distempers to form one series of events, 
that we have the pestilential constitution ox icaria- 
ra<Tig Aoi/zwcJ^f of the observing ancients, especially 
the Greek jihysicians. as clearly laid down as any 
aphorism in our science, and prognostics of pesti- 
lence framed accordingly. A volume might easily 
be filled with facts illustrative of this position- 
but we must premise one general remark, that, 
straitened as wc are, by the nature of the work, 
within narrow limits, yet in so comprehensive an 
argument some general results must necessarily 
be assumed; pledging ourselves at the same tim« 
for the truth of the principle, whilst we are omiv 
ting the details on which it is founded. 



EPIDEMICS. 



67 



[About the time cholera first made its appear- 
ance in England, in 1832, Dr. Prout noticed a 
positive increase in the weight of the air, similar to 
what might be produced by the difi'usion of a | 
heavy gaseous principle through the lower regions 
of the atmosphere. Sec art. Cuolera, Epidemic, 
p. 421.] 

Tliere can be little difTiculty in tracing a con- 
nection between intemperature of the seasons and 
famine or unvvholusome food; and the relation of 
the latter to the production of epidemic pestilence 
is more clearly manifest when we consider that its 
violence almost invariably falls upon the poor. 
It is a remark of Dr. IVlead, deduced from his pre- 
vious enquiries, and confirmed by every pestilen- 
tial epidemic subsequent to his time, " that it has 
never been known when the plague did not first 
begin among the poor." This observation is 
strengthened by the histories of the yellow fever 
in America and in the south of Spain, of the cho- 
lera in the east, and of our own epidemic fever, 
particularly in Ireland. The poor are the chief 
victims, because they are principally subjected to 
the exciting causes. (^Heberden, On the Increase 
and Decrease of Disease, &c.) 

Mortality among some tribes of the lower ani- 
mals not unfrequently follows intemperature of 
the seasons. Sometimes this mortality is noticed 
among dogs, cats, horses, and mules ; and some- 
times among sheep and cattle used as the food of 
man. In the pestilence that raged at New Or- 
leans in 1819, we are told that the cattle died : — 
" horses, oxen, and cows with rotten tongues ; 
sheep and hogs with their hoofs dropping off, and 
calves with rotten ears." Dr. Hodges bears a very 
striking testimony to this fact in his Loimologia, 
or Account of the Plague of London in 166.5 : — 
" Many knowing persons," he observes, " ascribed 
the pestilence to the quantity of bad meat from 
tlie preceding sickness among the cattle, which 
was sold so cheap to the poor that they fed upon 
it even to gluttony." " It is incredible to think 
how it raged among them — to such a degree that 
it Was called the poor^s plague." 

The question does not seem to have been cn- 
tertaincil, whether the same physical causes which 
acted upon the cattle might not have acted also on 
that part of the human species which was most 
exposed to elemental vicissitudes. 

Salvaresa supposes the ejiidemic fever of 1764, 
at Cadiz, was occasioned by the old and corrupted 
corn. " Amongst the poor," he says, " the disor- 
der was most violent. In this year the animals 
were first affected ; and the mortality wasj princi- 
pally observed among birds that fed on grain, as 
pigeons, poultry, &c." (Dr. Maclean.') 

In the fever of Cadiz of the year 1800, Sir 
James Fellowes asserts that " the air, from its 
stagnant state, became so vitiated, that its noxious 
qualities aiTected even animals; canary-birds died 
with blood issuing from their bills; and in all the 
neighbouring towns which were afterwards infect- 
ed, no sparrow ever appeared." (Dr. Good, vol. ii. 
p. 74.) 

Dr. Mead states that " it has been observed m 
times of the plague that the country has been for- 
saken by the birdij." This curious fact does not 
belong only to the form of pestilential fever called 
plague : it is one of the many phenomena which 



are scarcely reconcileable w.th the notion that 
gives to the causes of pestilence so confined a 
range as the intercourse with an infected individual 
or the exposure to fomites. Livy tells us that in 
the pestilence at Rome, A. U. C. 571, " not a vul- 
ture was to be seen for two years:" and Thucy- 
dides relates that in the plague of Athens " the 
birds that usually preyed on human flesh entirely 
disappeared." Diemerbroeck, the learned and can- 
did author of the work on the plague of Nimeguen 
in 1636, records that it often happened when 
canary-birds died without any obvious cause in 
any house, the plague showed itself not long after 
in some of the fiimily." He also states that birds 
were much more scarce than at other times : — 
"avium multo rarior numerus." It is mentioned 
by Dr. Short that " during the four months Dant- 
zic was aflSicted, in 1709, all kinds of birds, as 
swallows, crows, sparrows, &c. deserted the city." 

" A rubigo or mildew, i. e. a dew impregnated 
with highly corrosive powers, (see Hird on Pesti- 
lence, p. 91,) was anciently deemed one of the 
causes of epidemic diseases. The Romans, ap- 
prised of the pernicious effects of these mildews, 
instituted what they denominated yeste rubigalia, 
and worshipped an imaginary God under the 
name of Robigo. Hoffmann mentions such a 
dew, 'ros valde corrosivus,' as having infested 
vegetables in 1693-4, whence the cattle died in 
multitudes. (Tom. i. de Temp. Ann. Insalub.) 
And Ramazzii:i ascribes an epidemic to similar 
dews; at -vrirch time the vegetables, corn, and 
fruit becam»« black, being affected with a ' lues 
rubigalis.' The same year was remarkable for the 
scarcity of honey ; and most creatures that live 
upon what they extract from vegetables died or 
languished. Probably such occurrences led many 
of the ancient writers to mention the silence of the 
grasshopper, and the drooping inactivity of the bee 
and the silk-worm, among the presages of impend- 
ing pestilence. As to the spots, which are said to 
have assumed various forms, especially those of 
criiciculse or little crosses, and 1,0 have appeared 
suddenly on garments, utensils, &c. as they are 
recorded chiefly on the authority of monks, whose 
writings are highly tinged with super^jtition, they 
are scarcely worthy of serious consideration." 
(Rees' Cyclop, art. Epidemic.) 

Most of the writers who treat of the prognostics 
of pestilence refer to swarms of some of the insect 
tribes. Lord Bacon particularly remarks that 
" those years have been noted for pestilential, 
wherein there were great numbers of frogs, flies, 
locusts, &c." The plagues of Dantzic, Nimeguen, 
and Marseilles, and many others, afford illustra- 
tions of this fact. To give details of all the natural 
signs W'ould not be compatible with our object. 

2. To found a truth in science we must have 
recourse to general observations. Isolated facts 
are only valuable so far as they tend to establish 
general laws. There is no science in which what 
are called facts require to be viewed with more 
suspicion than in that of medicine; nor any de- 
partment of it where there is more room for erroi 
than in that which comprehends the invisiblo 
region of contagious miasms and atmospheric in. 
purities. We have the following general observa 
tion of Dr. Mead in relation to the matter hcSoiK- 
us: "Fevers of extraordinary malignity are th>* 



EPIDEMICS. 



usual forerunners of plague, and the natural con- 
sequence of that ill state of air which attends all 
plagues." This admission cannot but be consi- 
dered very important. It does not, however, depend 
upon the authority of Dr. Mead. 'I'he fact is con- 
firmed by a most ample induction. Fevers of 
extraordinary malignity, and other forms of mortal 
disease, have been olisen-ed to be the usual fore- 
runners of plague or epidemic pestilence in almost 
every country. (See Webster's History of Epide- 
mic Diseases ; and Researches into the Laws of 
Pestilence, by Thomas Hancock, M. D.) 

It was rather triumphantly stated that the plague 
of MaUa in 1813 formed an exception to this rule, 
in order to prove the position that the disease was 
imported from Alexandria; in fact, that no pre- 
cursor fever ushered in that pestilence : and if we 
had no other accounts of it than those by Faulk- 
ner and Tuliy, we should have been left somewhat 
in the dark on this point. But the candid and 
enlightened Dr. Heimen informs us that " for four 
or five years preceding that in which the plague 
raged, sudden deaths were more frequent than or- 
dinary, and during the twelve months immediately 
preceding, and esp( cially for the last month of the 
period, the increase was still more remarkable, in- 
somuch as greatly to excite public observation." 
(Edinburgh Medical and Physical Journal, No. 
104.) "Apoplexies (or sudden deaths) and other 
diseases were never so general or so numerous in 
the memory of man." 

" It is observable," says Dr. Heberden, (see his 
observations above quoted : p. 85,) " that at its 
first breaking out the disease has never been 
known to be the plague. It has moreover very 
generally been preceded by a severe putrid fever." 
The plagues of Venice in 1576, of London in 
1625 and 1665, of Nimeguen in 1636, of "Naples 
in 1656, of Marseilles in 1720, of Aleppo in 
1742 and 1760-3, of Holstein in 1764, and of 
Moscow in 1771, were all preceded by malignant 
fevers. 

Now if any one should inquire what are the 
effects of that peculiar state of air which ushers 
in an epidemic pestilence, the answer attested by 
long experience is, the occurrence of malignant 
fever. Thfs is one part of the history of such 
events. But let us notice more particularly the 
observation which Dr. Heberden has annexed to 
the statement of this fact, viz. : that " at its first 
breaking out, the disease has never been known 
to be the plague." The simple reason of this 
extraordinary circumstance, and of the doubts and 
dissensions which have sprung from it, is the 
gradual and imperceptible change of the malig- 
nant fever into the true pestilential fever or plague, 
and the contrariety of this fact to the medical 
systems and authorities which have assigned dif- 
ferent forms of the same disease to different classes 
and orders in nosology. We may almost take 
shame to ourselves that we belong to a profession 
which, either from the imperfection of the science 
itself, or from the deficient observation of its fol- 
lowers, has exhibited so many instances within 
the last two centuries in different countries, of 
reproachful contention among the faculty, on the 
eve of pestilence, about its name and nature; and 
which hitherto has laid down so few solid data to 
•e/'ure practitioners from future quarrels on the 



same, ground. Leaving the disputes » '""^ c°" 
tagion out of the question, the d.spu es about 
names or nosological terms have agitated ph>s.- 
cians in Italy and France, and Russia and Ger- 
many, and Spain and America, not excepting our 
own' country, till the sober and in.part.al members 
of the profession are mortified, and legislatures 
are wearied and disgusted; for the latter know 
not what is really matter of fact, and the former 
arc unwilling to ally themselves with such fierce 
combatants. Lord Bacon's aphorism, in its gene- 
ral signification, has been repeatedly confirmed 
since his time, that " the lesser infections ol small- 
pox, purple fever, agues, &c. in the preceding 
summer, and hovering all winter, do portend a 
great pestilence the summer following ; for putre- 
faction rises not to its height at once." Lord 
Bacon was too much of a philosopher to interpret 
the regular series of natural phenomena by his 
own fancies, and too little of a systematic writer 
on medicine to perplex himself with the trammels 
of artificial distinctions imposed by names. But 
some physicians have endeavoured to show that 
there was only a casual connection between the 
pestilential epidemic and the malignant fever, its 
forerunner ; and numbers have on such occasions 
involved themselves in keen disputes, whether the 
name of malignant fever or that of plague was 
the proper appellation of the epidemic pestilence 
itself. In this way they have too generally trod 
the thorny ground of contention instead of the 
simple path of faithful observation ; and the con- 
sequence is, that we have more of counter-state- 
ments than of unquestionable facts reported to us 
from the scene of every pestilential visitation. 

Nevertheless, all is not confusion ; and there 
are some things on which medical science may 
repose with satisfaction in reference to this {)art 
of the subject. Two important observations be- 
long to it : the one is, that the malignant fever 
which precedes the plague, commonly reappears 
at its decline ; and the other, that during the con- 
tinuance of the epidemic pestilence itself, at least 
during its active prevalence, all other forms of 
epidemic disease, such as those which are peculiar 
to the place and to the season of the year, are en- 
tirely extinguished. With regard to the former, 
it may be noticed, that one of the first and most 
evident signs of the epidemic pestilence being 
about to cease its ravages, is the appearance of 
another form of epidemic fever, generally of that 
which preceded, and sometimes of a new train of 
diseases; this new order of things indicating that 
the pestilential constitution is changed, or at least, 
the disposition in the air to foster and "spread the 
principal disease, completely for the time removed. 
The second fact is interesting, both from the anti- 
quity of the obser^'ation and from its accordance 
with modern experience ; that, while the tyrant 
disease is prevailing, it usurps complete,dominion, 
and suffers no other disease to appear of an epi- 
demic character. This was noticed in the plague 
of Athens, by Thucydides ; and every pesMlence 
since that memorable period has verified ihe ob- 
servation. It was noticed particularly in the last 
plague of Malta. A fact recorded by Sauvages, 
(Nosol. Method, vol. i. p. 415,) places tliis cir- 
cumstance in a very strong light, viz. that when 
the plague was raging in the south of France in 



EPIDEMICS. 



09 



1720-21, no greater number of persons died of 
the disease in the town of Alet — and none died 
of any other disease — during the year of its visi- 
tation, than used to be carried off by other dis- 
eases, though the plague absorbed all others, or in 
fact put them to flight while it was prevailing. 
This is an incontestable fact, and a suthcient an- 
swer to those who deny the operation of any 
general cause. For it is perfectly clear that if a 
vessel from Sidon brought the plague to Marseilles 
in 1720, as was alleged, and that the contagion 
was conveyed from thence to Alet in Languedoc 
in 1721, as was asserted, this accidental circum- 
stance, upon that hypothesis must have exerted a 
most extraordinary influence on the atmosphere 
of the town of Alet, or rather on the constitution 
of every one in it, if it put every other form of 
mortal disease to flight for a whole year after. 

The general remarks above made, relative to 
the forerunners of plague and its insidious ap- 
proaches and dominion over other diseases, apply 
also to the pestilential fever of Spain, and to the 
yellow fever of America. "The occurrences," 
says Dr. Halloran, "which preceded the epidemic 
of Barcelona in 1821, correspond with the old and 
recent observations on a similar subject in other 
countries; it almost invariably happening that the 
yellow fever of Spain is preceded by unusual dis- 
eases of various form and force, more jmrticularly 
by bilious remittent fevers, which are often so 
aggravated and malignant that physicians them- 
selves do not venture to define the line of demar- 
cation between them and the avowed epidemic." 
In the " Sketches of the Medical Topography of 
the Mediterranean," by Dr. Hennen, who closed 
his professional career at Gibraltar in 1828, and 
who observed and wrote with e(iual candour and 
ability, we find it stated that, "in 1813 bad re- 
mittent fevers preceded the epidemic which raged 
at Gibraltar, and that its true nature was disguis- 
ed, till it had made such progress as to be preva- 
lent in every quarter of the town. 

With regard to the transatlantic pestilence, 
Webster informs us that "the yellow fever never 
occurs in the temperate latitudes of America, ex- 
cept under a pestilential constitution of the air, 
manifested by other malignant diseases ; and that 
it has been preceded by acute diseases, and follow- 
ed bv remittents, dysentery, and malignant pleu- 
risy." 

3. We believe that the remark of Sydenham 
applies to the plague and the yellow fever, and 
the Indian cholera, and to every other form of epi- 
demic pestilence ; that " all epidemics at their 
first appearance seem to be of a more spirituous 
and subtile nature, in other words, more violent 
and acute, as far as can be judged from their 
symptoms, than when they become older." 

These changes or varieties in an epidemic pes- 
tilence, during a few months' career, might be 
considered at some length under three heads, viz. 
the proportional mortality, the appearance of the 
sjMnjjtoms, and the alleged diflference in the con- 
tagious properties ; but a veiy brief notice of each 
must suffice. 

As to the first, it appears to be a universal fact, 
that at the first rise of an epidemic pestilence, the 
proportional mortality is always greatest ; and, 
on the contrary, at the decline, whether a few 



months or weeks only comprise the who.e caieer, 
the disease loses much of its fatal character; 
putting entirely out of view the interference of 
medical art in either case. Knowing this to be 
the law, though we might not be surj)rised that, 
at the appearance of a new and formidable disease, 
when all is perplexity and alarm, medical men 
should be at a loss respecting the proper treat- 
ment, and should often vkitness the unequal con- 
flict of their science ; yet we can scarcely withhold 
a smile, when we see so much self-congratulation, 
and the numerous cases of recovery at the decline 
attributed to some improved fdan of treatment. 

With regard to the symptoms or outward 
character of an epidemic pestilence, we believe 
the assertion may be safely warranted, that it has 
never happened that the appearances were uniform 
in its beginning, height, and decline. As to the 
plague, this is well knov^m to be the case : Syden- 
ham, Russell, and others, note the fact. On the 
points of distinction between the varieties of the 
disorder we need not dvi'ell ; though it would be 
a work of no small practical utility to consider the 
usual periods in which the bubo, carbuncle, pur- 
ple spots, and milder features of the disease make 
their appearance. But if our hmits allowed, it 
might be shown that even the quick or apoplectic 
nature of the attacks at the commencement, bears 
a near affinity to some of those precursor diseases, 
which, in London, Marseilles, Aleppo, and Malta, 
ushered in the pestilence itself ^ and at the decline 
the mild features and diminished mortality exhibit 
a striking contrast with its previous violence and 
malignity. It would scarcely be right to conclude 
this part of the subject without noticing an obser- 
vation of Sir James M'Grigor, showing the varie- 
ties which the same disease will sometimes assume 
under the influence of different localities and sea 
sons. " When the plague first broke out in the 
Indian army in Egypt, the cases sent from the 
crowded hospitals of the sixty-first and eightj^- 
eighth regiments, were from the commencement 
attended with the typhoid or low symptoms. 
Those which were sent from the Bengal battalion, 
when the army was encamped near the marsh of 
El-Hammed, were all of the intirmittent and re- 
mittent type. The cases vv'hich occurred in the 
cold rainy months of December and January had 
much of the inflammatory diathesis ; and in the 
end of the season, at Cairo, Ghiza, Boulac, and 
on crossing the isthmus of Suez, the disease wore 
the form of a mild continued fever." 

With regard to the appearances of the yellow 
fever in Philadelphia in 1793, Dr. Rush tells us, 
that « the frequent absence of a yellow colour led 
to mistakes which cost the city several hundred 
lives ;" as the want of inguinal tumours at the 
rise of the plague of Messina in 1743, cause<> 
thirty-three physicians out of thirty-four to deny 
the pestilential nature of the disorder, and to neg 
Icct the proper means of checking it, till it was 
too late. 

It might appear that we were departing from 
the rule at first laid down, and entering upon dis- 
putable ground by taking any notice of conta- 
gion ; but the observations to be made bemg 
formed by decided advocates of that doctrine, they 
ought at least to merit due attention from all who 
do not deny it, especially from those who ascribe 



70 



EPIDEMICS. 



so much more to contagion than to atmospheric 
influence. Dr. Russell informs us that at the be- 
ginning of an epidemic plague the contagion is 
so feeble, in other words, so many of the attend- 
ants escape infection, and such long intervals oc- 
cur between the cases, as to cause serious perplex- 
ity respecting the nature of the disorder, (Russell 
on the Plague, pp. 19 and 261); and that the 
contagious property is nearly, if not quite extin- 
guished, at the decline, both in persons and clothes, 
must be obvious to every unbiassed observer who 
considers the facts; for the disease has never 
ceased in any place for want of subjects to act 
upon, (Researches, p. 156.) And the compre- 
hensive remark of Dr. Russell is a striking an- 
swer to those who can trace the extinction of an 
epidemic plague to no other means than police 
regulations. It is in these w-ords : " From what 
has been said of London, Aleppo, and Marseilles, 
it would seem as if there was little observable dif- 
ference in the mode of its termination, in cities 
where purification was practised and where it was 
not." 

In all stages of the biUous pestilence of Amer- 
ica, its contagious property is so indistinctly mark- 
ed, that Dr. Rush felt himself obliged to confess 
that " the interests of humanity were deeply con- 
cerned in the admission of the rare and feeble 
contagion of the yellow fever." And although 
contagion is what popular opinion fixes upon the 
plague as its necessary attribute, yet there cannot 
be a shadow of doubt, that at all times this con- 
tagious property of the disease depends on so 
many contingencies to give it force, as to justify 
the remark of Dr. Russell, " that the dread of 
contagion from plague may, consistently with 
truth, l)e moilerated." 

Dr. Russell sums up the matter in these words, 
after staling that " the constitution of the air is 
the cause which heightens or lessens the suscep- 
tibility of the contagion." — '< 1st. In the begin- 
ning of a pestilence the disease, though less con- 
tagious, appears in its most fatal form. 2d. On 
its increase and height, though manifestly more 
infectious, the malignity of the effluvia does not 
seem to be exacerbated, because milder forms of 
the disease are then more common. 3d. Several 
persons infected from the same subject are vari- 
ously afflicted ; some in a greater, some in a lesser 
degree, the disease being modified by difference in 
constitution. And lastly, persons in constant 
communication with the sick who have resisted 
infection in the most contagious stages of a pesti- 
lence, are sometimes attacked in its declining 
state ; which seems to indicate some change in 
the habit of the individual, not the increased ac- 
tivity of the contagious effluvia," (Treatise on the 
Plague, p. 261.) "At Aleppo there were in- 
stances of persons who had exposed themselves 
two or three successive seasons, being attacked at 
length whe.i the contagion was fa.st on the decline, 
and the distemper had become in all respects mild- 
er," (Treatise on the Plague, p. 301.) 

In considering the progress of an epidemic pes- 
tilence from one country or city to another, it must 
be viewed as a remarkable fact, that a disease 
which has become so mild as to lose the power of 
iloinar mischief in one place, when transferred to 
Hiio'h^'- should begin in the sa-Tie insidious and 



destructive manner, and continue to rage with 
the same violence, and at last moderate its fury in 
the same way as it was observed to do in the 
former ; making due allowance for the variety of 
circumstances which must tend to modify the 
effects in different places. On the common ex- 
emption of strangers and others we have not time 
or space to enlarge. 

4. The evidence wb^ch bears upon the connec- 
tion of pestilence wita filth, &c., is remarkable : 
it is both negative and positive. The negative is 
the absence of pestilence from those cities of Eu- 
rope, now for more than a century and a half, 
which have adopted a system of health-police, not 
by guarding against foreign contagion, but by do- 
mestic cleanliness. The positive is the devasta- 
tion of those where attention has not been paid 
to these points ; and the immediate good effects 
which have resulted from sanatory regulation; 
wherever thej^ have been adopted. " Dr. Heber- 
den," as was observed by Bateman in an able 
article on the subject, " has collected the most 
ample and satisfactory evidence of the connection 
of plague and of the malignant contagious fever, 
which usually precedes and accompanies it, (if, 
indeed, they be not modifications of one and the 
same disease,) with the filth of crowded, ill-con- 
structed large cities, in all ages and countries." 
London, Paris, and the cities of the Netherlands, 
which were formerly scourged by pestilence, when- 
ever untoward causes operated, such as wars, un- 
cultivated fields, famine, or unwholesome food, 
wretchedness occurring in a congregated mass of 
human beings, added to irregular seasons and in- 
temperature of the climate, have been compara- 
tively exempt from its visitations since their streets 
were paved and widened, and kept clean from 
animal and vegetable filth, which formerly lay in 
heaps under a scorching sun ; since sew-ers have 
been dug, and fresh water has been abundantly 
supplied to them ; since houses have been better 
ventilated, and built more for the purposes of 
health than of harbouring the greatest mass of 
people in the smallest possible space ; and since 
all kinds of stagnant pools have been removed 
from their vicinity. And, besides the exemption 
from pestilence, the type and character of the 
reigning diseases in some of these cities have been 
much changed for the better ; and the relative 
mortality has been wonderfully diminished. This 
is strikingly exemplified in London. 

But as it was always in the most fiUhy parts 
of those cities that plague " originated and main- 
tained its head-quarters," so, in other cities, which 
have been tardy in adopting such improvements, 
as Marseilles, Moscow, and other places, there was 
a corresponding liability to its invasion much later 
than the period above noticed. And now, if we 
turn our attention to the domestic sources of ma- 
lignant fever still subsisting in the cities of Spain, 
which have so often been scourged with it of late 
years ; or to the present state of Constantinople, 
Cairo, and Alexandria, we need not wonder at the 
facts which experience has thus unfolded to us 
from time to time in confirmation of these princi- 
ples. " AH the towns and cities (in Spain) which 
sullered from the yellow fever were, with the ex- 
ception of Cadiz, fihhy in the extreme, dis-ust- 
ingly so, and very objectionable on the score of 



EPIDEMICS. 



n 



ventilation, situation, and form of construction ; 
while the different towns of Areas, Matero, Bada- 
loiia, Tarragona, Vimaros, Benicarla, Valencia, 
Alcama, Velez, Malaga, Marahella, Este-^ona, 
Vcjer, Conil, Puerto Real, Rota Chipiona Orcos, 
and Medina Sidonia, all of which are in the vi- 
cinity of the sea, and which, it may be presumed, 
from their relative situations, communicate freely 
with the theatres of disease, were not affected by 
the malady. They seldom, indeed, suffered in 
any o'.her years ; because, independent of their 
localities being better chosen for health, they are 
comparatively clean." (Good's Study of Medi- 
cine, vol. ii. p. 81.) 

In the cities of the east which are still scourged 
with the plague, they nourish from year to year 
the seeds of the disorder in their own bosoms, in 
climates, too, the most favourable to the propaga- 
tion of pestilential epidemics ; yet in these very 
[)laces it is only in seasons when aggravated 
causes have been operating, that pestilence in an 
epideniic form appears; and when it does show 
itself, the phenomena of its beginning, and height, 
and decline, correspond with those which have 
been stated to occur in other places, allowing for 
the difference of climate. Sir John Webb notes 
the common epidemic, or rather endemic, preva- 
lence of plague in Egypt in these words : and the 
reader is requested to bear in mind the difference 
in the violence and symptoms of the disease in its 
beginning and decline. " The course of the dis- 
ease is nearly the same every year, and equally 
varies in different seasons of the year. In Egypt 
it commences in November, at which time it rages 
with its most deadly malignity ; and those who 
are affected by it sink into the grave almost with- 
out complaint. It continues its ravages with little 
abatement through the winter and the earlier part 
of the spring, when, as the weather becomes 
warmer by the approach of summer, its attacks 
are less frequent, its symptoms much milder, and 
it subsides into a manageable malady." Pappon, 
a late French writer, tells us, that even in Egypt, 
when it was formerly well cultivated, the climate 
was healthy compared with that of Rome in its 
decline. 

Wilh regard to the indigenous causes adequate 
to the production of yellow fever or the transat- 
lantic plague, which Dr. Rush had frequently an 
opportunity of observing, he states, " Philadelphia 
must admit the unwelcome truth sooner or later, 
that the yellow fever is engendered in her own 
bowels ; or she must renounce her character for 
knowledge and policy, and perhaps with it her 
existence as a commercial city." 

Although extensive marshes give rise to diseases 
of a febrile character every year among those re- 
siding in their vicinity, yet it is often found that, 
in seasons of uncommon intemperature, the ma- 
lignity and fatality of such diseases are much in- 
creased. And this cause, concurring with other 
circumstances, has frequently produced a destruc- 
tive pestilence. 

Diodorus attributes a pestilential disease which 
occurred among the Carthaginians at the siege of 
Syracuse to the following combination of circum- 
stances: — " the multitude of people confined with- 
in a narrow compass, the situation of the camp in 
a low and wet ground, and the scorching heats in 



the middle of the day, succeeded by cold and damp 
air from the marshes in the night." Fracastorius 
ascribes a malignant epidemic fever in Italy, in 
the sixteenth century, to an extraordinary inunda- 
tion of the Po, which, happening in the spring, 
left marshes, and, those corrupting, infected the 
air through the summer. Forestus remarks, that 
from the putrefaction of the water only, the city 
of Dellt, where he practised, was scarcely ten 
years free from the plague or some pestilential 
distemper, (Rees' Cyclop. Art. Epid. Dis.) "At 
this day," says Assalini, " the lakes, the marshes, 
and the filthiness which one finds in the cities of 
Lower Egypt, are the principal causes of the fre- 
quent diseases to which they are subject, and 
which can never be eradicated until we have found 
means to purify the atmosphere of their environs. 
This important advantage may be obtained by 
draining off the water of the lakes, and filling 
them up ; by keeping the cities clean, paving them, 
and giving a free exit to the rain water, which, 
stagnating in different parts of these cities, becomes 
corrupted, and, conjoined with filth, infects the 
atmosphere. By similar operations several cities 
and provinces in Europe, America, and the Indies, 
have been rendered healthy. The inhabitants of 
the citadel of Cairo, which is favourably situated 
oa an eminence, during the plague of 1791 were 
exempt from the disease, which laid waste the 
lower town ; with which, nevertheless, they con- 
tinued to hold constant intercourse." 

Bombay has been rendered much more healthy 
than it was formerly, by a wall built to shut out 
the sea, which formed a salt marsh, and by an 
order that none of the natives should manure their 
cocoa-nut trees with putrid ilsli. (Lind on Hot 
Climates, p. 207). According to Diogones Laer- 
tius, Einpedocles, the Sicilian philosopher, removed 
pestilential diseases from the Salenuntians, by con- 
veying two streams of running water into the stag- 
nating river round their city which gave rise to 
them. (Diemerbroeck de Peste.) Modena was 
subject to malignant fevers from a like cause ; and 
by filling up the ditches and morasses which sur- 
round the citadel, these fevers have almost disap- 
peared. (See Assalini, p. 208.) 

5. It is a singular illustration of the preceding 
views, that in none of the quarantine establish- 
ments on the continent, and in none of the stations 
appointed for the purpose in the British islands, 
along so great an extent of coast, engaged in such 
universal commerce, and for such a number of 
years, hag there ever been an instance of a person 
suffering death in the process of expurgation or 
purification of goods imported from countries 
afflicted with pestilence. Evidence to this effect, 
so far as it relates to our own shores, wa^ laid 
before a select committee of the House of Com- 
mons, in 1819. (Researches into the Laws of 
Pestilence, by T. Hancock, M. D. p. 23.3.) 

Professor Assalini, who has given us some 
interesting particulars concerning the plague of 
Egypt, communicates the result of his inquiries 
respecting the matter in question in these words : 
" It has often been said, that in breaking open a 
letter, or in opening a bale of cotton containing 
the germ of the plague, men have been struck 
down and killed by the pestilential vapour. I 
have never been able to meet with a single eye- 



EPIDEMICS. 



witness of this fact, notwithstanding the inquiries 
which I have maJc in the lazarettos of Marseilles, 
of Toulon, of Genoa, Spczia, Leghorn, Malta, and 
in the Levant. All agree in repeating that they 
liave heard of such an occurrence, but that they 
have never seen it happen. Citizen Martin, cap- 
tain of the lazaretto at Marseilles, who for thirty 
years has held that situation, told me that during 
that time he had seen opened and emptied some 
millions of bales of cotton, silk, furs, feathers, and 
other goods coining from several places where the 
plague raged, without having ever seen a single 
accident of the liind." The chief physician of 
the lazaretto at Malta informed Dr. Maclean that 
during the period of fifteen years in which he 
frequented the lazaretto, no cargo arrived, the 
expurgation of which infected a single individual 
in the establishment ; and according to the testi- 
mony of the deputy-inspector Grieves, none of the 
persons so employed were affected in that island 
during the plague of 181.3. 

If we go to the Levant, we have the evidence 
of Sir James Porter, that " all sorts of merchan- 
dise susceptible of infection pass through the 
hands of our Enghsh factors at Aleppo, Smyrna, 
or the places from whence they are shipped ; they 
are examined strictly by them, or by their ser- 
vants ; and there is not upon record, nor has a 
single living witness ever related an instance of an 
English factor or servant dying of the plague, at 
any of the sea-port towns, or in any other part of 
Syria or Asia Minor, and but one only in Con- 
stantinople, in almost a century ; though the 
disease very frequently rages in that metropolis." 
(Russell on the Plague, p. 309.) 

In connecting together the preceding classes of 
facts and observations, it is necessary to premise 
that a mere sketch is only given, and very general 
conclusions only can be drawn ; but we believe 
that no theory of epidemic diseases will be perfect 
which does not include a comprehensive survey of 
all these circumstances. 

As to the phenomena of the weather and sea- 
sons, it must be allowed that the physical signs 
deduced from their intemperature and irregulari- 
ties, such as blights, mildew, abundance of insects 
and reptiles, flight and death of birds, murrain 
among cattle, and pestilence among brutes, are 
uncertain in their development in different coun- 
tries, and even in the same ; and that some pesti- 
lential visitations have occurred without any very 
striking signs of this sort having been noticed. 
But though this may have been the case, it does 
not appear that extremes of some sort have ever 
been wanting in the air and seasons as accessories 
to the cause. The uncertainty, however, in 
egard to the outward ^•isible signs of atmospheric 
impurity, as recognized in the mnnlfest qualities 
of the air, has induced some philosophers to sup- 
pose that there were liifent qualities which neither 
our senses nor chemical knowledge could detect, 
implicated in the causes of the mischief. Some, 
accordingly, have given reins to their fancy, if 
they have not also given occasion to the advocates 
of contagion to confirm tlieir exclusive opinions, 
in seeking for the cause of epidemic pestilence in 
mineral exhalations from the bowels of the earth, 
emitted by volcanoes, earthquakes, and such-like 
'onvulsions. But though we may have some 



persons admitting a corruption of the air by 
mineral vapours, and others a contagious semi- 
nium as being necessary to the effect ; yet a cor- 
rupt .ir which cannot be detected, and a conta- 
gious p.inciple which must be hunted for in a 
variety ot channels, and is constantly eluding the 
search, may still leave the truth in as much ob- 
scurity as it was before. We are therefore com- 
pelled to leave such unsubstantial hypotheses, for 
they only remove the ditriculty a step. The notion 
of Sydenham, however, " that epidemic diseases 
arise from mineral vapours from the inmost bow- 
els of the earth," comes somewhat nearer the 
truth, if we connect it with the etHuvia and the 
effects of local filth and of animal and vegetable 
impurities in large, ill-constructed cities and 
marshy situations. In situations of this sort 
vapours do indeed, at times, rise from the earth, 
(if not mineral impregnations,) which are known 
to be highly destructive. Yet, on the other hand, 
if local causes like these are existing year after 
year, and a general pestilence is but rare, how are 
these to be considered the cause ? It cannot be 
doubted that local filth alone will not explain the 
circumstance. Like atmospheric intemperature it 
may contribute something, but it is not the cause. 
If, however, we add to the effects of unseasonable 
weather and of corrupting animal and vegetable 
materials, those of deficient or unwholesome food, 
and congregate the poor victims together in close 
sordid dwellings, surrounded and contaminated 
by local filth, then we fill up the range of pre- 
disposing causes which prepare the debilitated 
bodies of the wretched poor for the sudden inva- 
sion of acute disease, and lay them prostrate 
before the sweep of pestilence. But of famine, or 
unwholesome food alone, it may of truth be predi- 
cated, as of other individual causes, that it will 
not produce a pestilence. So that neither irregu- 
lar seasons and bad weather alone, nor the effluvia 
from putrefying animal and vegetable substances 
alone, nor vitiated bodily secretions, however con- 
centrated, alone, nor even diseased human secre- 
tions, the product of fever, however aggravated, 
alone, whatever marvellous stories may be attached 
by different authors to any of these particular cir- 
cumstances, will ever be likely to produce a gene- 
ral pestilence. This opinion is hazarded, not 
without being duly weighed, after a careful 
inquiry into the specific effects of these several 
causes, viz. : atmospheric vicissitudes ; animal 
and vegetable putrefaction ; malaria, whether from 
marshes or the mouths of great rivers, or cities or 
camps ; famine or bad food ; and the concentrated 
poison of human filth and human disease. Yet 
the wTiter of this article is not the less assured 
that all these causes together have a powerful 
combined influence in occasioning that predispo- 
sition of body without which no epidemic plague 
will make any progress ; without which no con- 
tagion will spread ; and which, if in some few 
cases it require the assistance of a contagious 
principle to produce the disease in time of pesti- 
lence, yet in the majority of instances appears to 
surrender the multitude a prey to the common 
enemy without the medium of contagious inter- 
course. jVor is it, on the other hand, to be 
doubted that fear, wretchedness, fatigue, and 
excess, with other debilitating powers, both in an 



EPIDEMICS. 



73 



epidemic season and at other tirhes, may co-oper- 1 in any city, as the constant and habitual means 
ate with some of the predisposing causes above of preservation. 

mentioned ; and, perhaps, with contagion, to pro- Now, unquestionably, the removal from close 
duce the disease even in the bodies of those who, I and filthy habitations and a vitiated neighbour- 
living in the comforts of life, have been subjected j hood to a pure air, if such can be found ; and the 
neither to the undermining etfects of bad food, ' separation from each other, and dispersion over a 



nor to the corrupting influence of a vitiated air 
and local filth. It is probable that a predisposition 
is formed, occasionally, to take the disease in this 
way ; but that it is very rare, and never has been 
the cause of general pestilence. 

As far as facts therefore enable us to form any 
general conclusions in regard to the circumstances 
which conspire to produce a pestilence, the fol- 
lowing appear to be legitimate deductions, without 
having recourse to the obscure notion of a pcsti- 



large space of healthy ground, of the distressed 
multitudes who are thus predisposed, and the sup- 
ply of suflicient and wholesome food to them ; 
and cleanliness in their persons, clothes, and apart- 
ments ; have been fully ascertained to be the best 
prophylactics, even in time of pestilence, which 
human skill can devise, and the surest means of 
arresting this formidable evil. The citizens of the 
United States know well what security lies in 
these means ; the principles are not visionary. 



lential constitution of the air, except in so far as ' And here we must protest against the unscientific 
we may apprehend it as an ultimate fact, for it is \ attempt to establish a specific difference between 
in vain to inquire into the subordinate reasons, the Levant plague and the yellow fever, as to the 
why an epidemic pestilence, in obedience to the former possessing a contagious property, and the 
laws of this constitution of the air, either observes , latter none. It is astonishing that a physician 
certain seasons of the year, or a limited number i with a mind so energetic as Dr. Bancroft pos- 
of weeks or months to run its course, or a pro- ! sesscd, should have wasted his strength with so 
gressive movement in families and neighbourhoods, ' much pertinacity in that ineffectual labour. Too 
and cities and countries. I much stress has without question been laid upon 

1. Intemperature of the air, or a series of un- | contagion in both diseases. To take this quality, 



usual and irregular weather, lays the foundation 
for an acute disease in a congregated mass of hu- 
man beings. 

3. Deficient or unwholesome food predisposes 
the bodies of the poor, especially, to be acted upon 
by this intemperature. 

3. Local impurities, composed of effluvia from 
putrefying substances, in the vicinity of marshy 
situations or of large filthy cities, in proportion to 
their extent and to the concentration and viru- 
lence of the miasmata, aggravate the preceding 
causes by a partial pollution of the air. 

4. Human secretions and excretions, hurtful 
in this state of the body even without actual dis- 



which is only incidental, from one of these di; 
eases, in order to give it to the other in excess, 
when it is known that some deny it even to the 
latter, is not the way to advance our knowledge 
of this subject. But it might appear invidious to 
place in contrast with means of preservation and 
precaution like those just mentioned, the modern 
European policy of keeping our fellow-creatures, 
when threatened or afflicted with pestilence, shut 
up in the hot-bed of disease ; the sick and the 
healthy within files of bayonets, or in the hold of 
a vessel with a crowded and exhausted crew. 
Precautions like these, though in good truth their 
necessity is much to be doubted, we may not call 



ease, but become virulent by accumulation, and i barbarous and unenlightened, if they be sane- 



poisonous when subjected to fever, acquire a de- 
gree of malignity which is proportioned to the 
congregated mass. 

Hence, if the air, and the soil, and the food, 
and the state of the animal secretions contribute 
each a part to the production of a pestilential 
fever, it cannot be said that the cause resides 
wholly in any one of them. From the combined 
effects of all, however, a predisposition is formed 
which makes some inhabitants of a town or city 
liable to pestilence sooner than others, some towns 
or cities sooner than others, some nations sooner 
than others, in proportion as they have been sub- 
jected to the causes before mentioned. If so 
many causes did not successively concur to this 
effect, pestilence would be much more common 
than it fortunately is. We do not depend, there- 
fore, upon the casualties of arresting contagious 
intercourse, or of expurgating imported fomites, 
but upon the rare occurrence of the several sub- 
ordinate causes, for our exemption. 

And if the prudent adoption of some salutary 
regulations should prove availing, even in the 
verv lime of a pestilential visitation, to lessen the 
mortality and to mitigate the disease, as they have 
been often found to do, nmch more should such 
measures prove availing, when practically adopted 

Vol. II.— 10 G 



tinned by a British senate, nor inhuman, though 
practised by Christian governments of the nine- 
teenth century, in direct opposition to the benevo- 
lent usages of Greeks and Romans, and even 
modern Pagans ! But we do call barbarous, and 
unenlightened, and inhuman, the conduct of those 
members of our own profession at Noya, who, 
through fear of ihe contagion, " carried a spear in 
their hands for the purpose of killing any patient 
(and the case really happened) who in a fit of de- 
lirium might attempt to seize the physician or 
attendants." (Quarterly Journal of Foreign Me- 
dicine, No. 5, page 7.) Our abhorrence of such 
cowardice and cruelty is scarcely to be expressed 
in any temperate form of words. No reasonable 
man can doubt that the sacrifice of human life 
from the unwarranted, and, in its effects, unfeel- 
ing dread of contagion, operating as it does 
throughout all its details of practical ap[)lication 
from year to year, is and has been enormous. 

But, on the other hand, to maintain that indis- 
criminate intercourse may be allowed between the 
sick and the predisposed in their impure dwell 
ings, and that humsn beings may be cooped \.c 
together, in plague or yellow fever, or Indian cho 
lera, or malignant typhus, or dysentery, withju 
adding either to their own danger, or to that ol 



74 



their attendants, is to take that ultra view whicli 
is opposed to the experience of all ages. We do 
not want nice distinctions about a contagious and 
infectious atmosphere for practical purposes ; tiiey 
arc terms which give occasion to many words and 
to little practical good. The effects of each have 
been overstated, and of none more than of conta- 
gion, when viewed apart from other circumstan- 
ces. Contagion of any disease can do but little 
harm at any time, in any country, unless there be 
a strong predisposition of body concurring with a 
pestilential season. The signs or indications of 
ibis pestilential season, and the way to remove 
this predisposition, are of far more consequence 
than the precaution against a foreign contagion. 
Judicious and moderate physicians are more and 
more tending to this view of the subject. 

Contagion is not a necessary incident of any 
disease ; but some look upon it as constituting 
the very essence. A few brief remarks on this 
subject may perhaps be suitable in this place. 
The public are wearied with statements from me- 
dical men, that such and such diseases, of an epi- 
demic nature, are contagious, and that they are 
not contagious. They may well wonder at the 
imperfect state of a science which has not yet set- 
tled points of so much importance. What are 
thinking men to conclude when they see medical 
authorities thus opposed to each other ? — either 
that the opinion of the most eminent physicians 
is good for nothing, or that both parties are right 
— in fact, that under peculiar circumstances, these 
diseases are sometimes contagious and sometimes 
not. But it is a great misfortune that partial ob- 
servers allow their minds to be tinctured with ex- 
clusive opinions, of which they become as tena- 
cious as if these opinions could be verified by an 
undoubted demonstration. The consequence is, 
that little weight attaches to either side. It is too 
much the habit of all persons to look at pestilen- 
tial fevers of every kind, as if contagion was the 
quality which peculiarly characterized them. But 



EPIDEMICS. 

yellow fever take up three or four months ? If 
cholera halts days between the first few cases, 
pestilential fever halts weeks. Cholera observes 
precisely the same law as pestilential fever, when 
epidemic ; it is violent and fatal at the be:>inning, 
mild and harmless at the decline ; and, if its con- 
tagious nature were as well marked as that of 
plague, we should have the not less remarkable 
fact, that when it was most violent, and acute, 
and fatal, it was least contagious, except at the 
decline, when, as in plague, contagion is extinct. 

The preceding remarks have occurred in relation 
to the predisposing causes of pestilential diseases, 
which, perhaps, in most cases, go nine-tenths of 
the way in producing an attack of the disease, or 
only wait for some exciting cause while the body 
is already on the verge of pestilence. It remains 
to offer a few observations on the precursor dis- 
eases. 

That no pestilence comes alone, or without 
some heralds of its approach, seems to be a truth 
fully established in the unvarnished history of 
every such event. In most places it is the crisis 
of a series of fatal and uncommon diseases. The 
forerunner of plague is usually a malignant fever 
— of yellow fever, a fatal remittent ; which often 
appear again at the decline. The difficulty of 
distinguishing between this malignant fever and 
the pestilence itself has never failed to excite dis- 
sension among the faculty, both as to the name 
of the disease and as to its contagious property. 
These disputes belong essentially to the present 
state of opinion on this most important subject; 
and until correct views prevail over Europe, there 
will not be a pestilential visitation without them. 
We can easily account for this difficulty ; for what 
nature has joined, both in series and affinity, man 
has attempted to disjoin. Physicians, therefore, 
have perplexed themselves with the most unac- 
countable dilemma that ever found its way into 
any science. They have acknowledged a disease 
called malignant fever, which has ushered in an 



any one that the animal effluvia, or morbid secre 
tion from a diseased body, which constitutes con- 
tagion, is not necessarily a poison to all who come 
within its influence. Small-pox contagion itself 
is inoffensive to thousands. In those who have 
had the disease the predisposition is destroyed. 
There must be a strong predisposition of body to 
receive the contagion of any other disease ; and 
this strong predisposition is what lays the multi- 
tude prostrate before an epidemic pestilence : .so 
that, in some cases, an intense dose of the poison ; 
in others, its protracted application ; in others, an 
exhausted state of the body from defective nour- 
ishment ; in others, extreme fatigue and watch- 
ing, with mental depression ; in others, the de- 
bility which follows a debauch ; proves, one or 
the other, to be the exciting cause which brings 
this predisposition into action while the epidemic 
constitution, whether this depends on the air, or 
the body, or the season, is prevailing. It is no 
fanciful idea that an epidemic constitution is thus 
limited ; for how otherwise could it happen that 
cholera, like influenza, requires but six or eit'ht 
weeks to run its course, to become, in fact mild 
and impotent, after it has raged with fury ; while 
the Levant plague and the bilious pestilence or 



a very simple view of the case should convince epidemic pestilence, (o be their own, or at least 

the product of the country where it appeared ; but 
as soon as a little change in its character has taken 
place — which amounts to nothing more than a 
change in degree, not nearly so great as that which 
takes place in the pestilence itself, in the short 
course of its career — which change in a few 
months is put off again, ihe7i it is to be accounted 
of foreign origin, and ships and goods are con- 
demned as the supposed channels of introduction; 
or it is well if even human life, as has often been 
the case, docs not pay the penalty. The word 
contagion, with the fears attached to it, has been 
suffered to preoccupy the minds of statesmen and 
of many eminent jiractitioners to such a degree as 
to destroy all scientific research, to send them 
huntmg after an ignis futuus, which never yet 
was found, and to cause them to neglect those 
wholesome internal regulations which, if well 
observed, might bid defiance to all foreign conta- 
gions, supersede quarantine, and in great measure 
relieve commerce from its present injurious re- 
straints. •' 

With respect to that law of pestilence above 
alluded to, according to which other forms of acute 
disease arc banished while the epidemic pestilence 
continues to prevail, it is absolutely incredible oi 



EPIDEMICS — EPILEPSY. 



at least inexplicable on any sound principles, that 
one epidemic disease — whether plague, or bilious 
pestilence, or yellow fever, or cliolera — which 
banishes a whole host of other epidemic diseases 
from any country while it is raging, and then 
suffers them to start up when it is about to disap- 
pear, should owe its origin to any other place than 
to that country. It is quite incredible that the for- 
tuitous importation of a foreign contagion should 
so entirely change the atmosphere of a country, 
on which its minor epidemics manifestly depend, 
as to drive them away in this manner, in order 
that it may exercise the power of destroying alone, 
until it shall withdraw itself to act the same tra- 
gedy in some other place ; not only so, but that 
the presence of this foreign disease should restrain 
for the time the operation of the ordinary causes 
of mortality from the common acute and chronic 
diseases to which the inhabitants are liable, which 
is known to be in great measure the case during 
the rage of an epidemic pestilence. 

We might also lay some stress upon the fact 
that, with singular power of selection, an epidemic 
pestilence chooses its own season of the year, from 
which it is observed to vary but little in the same 
country or climate, both to begin and to conclude 
its ravages. 

If, in addition to these things, we consider the 
epidemic pestilence itself, and its varying features 
and character in its short career, we can arrive at 
no other reasonable conclusion than that it ori 
nates entirely where it rages. We have seen that 
no pestilential epidemic is one form of disease, of 
unvarying type and destructive power, from the 
beginning to the conclusion ; nor, by the admis- 
sion of the great advocates of contagion them- 
selves, of equal contagious property in its different 
stages, if indeed it be possible to ascertain this 
point, which is a question ; and the question 
hinges upon the very slight degree of contagious 
property manifested at the commencement, when 
the disease is most malignant and most fatal, as 
well as upon the acknowledged extinction of con- 
tagious property at the decline. 

By these facts we are compelled to admit that 
such a change takes place in the air. or in the state 
of the miasmata from the soil, or in the human 
body, perhaps in all together — a change so extra- 
ordinary as to alter the type and character of a 
pestilential disease from a fierce to a mild state, 
and to expel it entirely, destroying every vestige 
of contagious property in it; but according to the 
doctrine of imported contagion, we must not admit 
that any combination of indigenous causes can 
produce it. 

We are called upon by the facts to admit that 
the precursor malignant fever, which is so nearly 
allied to plague that the most sagacious physicians 
have allowed their inability to distinguish them, 
is an indigenous disease ; but, in condescension 
to common opinion, we must persuade ourselves 
that the disease which expels this native malig- 
nant fever, and that only for a time, is foreign ! 
It is marvellous that men of science could ever 
have been inlhienced to lend their sanction to 
such incongruous notions. But, in truth, the 
difficulty of ascertaining the real facts has been 
the cause of much erroneous opinion. 

Upon principles which allow of the domestic 



origin of pestilence, we can more easily explain 
the singular facts so frequently recorded in the 
annals of epidemic diseases, relative to the exemp- 
tion of foreigners, as well as of the inhabitants of 
other cities, in a place visited with pestilence. 
Many facts seem to indicate that it is not the Im- 
mediate state of things only which is to be taken 
into account, in order to explain the true causes 
of pestilence; but that the undermining effects of 
some remote causes, which have been some time 
in secret operation in certain communities, ought 
also to be considered ; for it is abundantly proved 
that a peculiar constitution of the air, on which 
the progress of pestilence in part depends, will not 
of itself induce the disease in strangers even hold- 
ing intercourse with the sick inhabitants, without 
a fit habit of body to receive it. And, on princi- 
ples like these, we can account for the escape of 
such inhabitants of the place as are living in clean 
secluded situations, enjoying all the necessaries of 
life, and but little exposed to the exciting causes — 
as in well-regulated hospitals and abbeys — far 
more satisfactorily than on the supposition that 
they have been guarded from the contagion. 

It is scarcely necessary to recapitulate the facts 
illustrative of the same views, and establishing the 
same principles, which belong to the exemption 
of those cities from the ravages of pestilence, 
where the wise regulations of cleanliness and at- 
tention to the poor have been adopted ; and, con- 
versely, the continuing liability of those in which 
these wholesome rules are neglected. 

If we wanted evidence of every other kind, the 
testimonies of those who have superintended laza- 
rettos and quarantine stations, furnish an argu- 
ment of no small weight against the doctrine of 
imported febrile contagion having in any case been 
a cause of general pestilence ; for the confused and 
contradictory accounts of the supposed channels 
by which contagion has been alleged to be con 
veyed into different countries, of which many ex 
amples could easily be furnished, might of them 
selves occasion serious doubts upon the subject. 

In conclusion, the separate points of evidence 
added together and weighed impartially, constitute 
a theory or system of connected observations and 
dependent results, tending remarkablj' to establish 
the opinion, with as much certainty as the case 
will admit, that the whole apparatus of an epi 
demic pestilence, from beginning to end, is th> 
production of the country where it rages. 

T. Hancock.. 

EPILEPSY. — Every one is aware of the dif 
culties with which the consideration of this disease 
is encompassed, especially with regard to its eti 
ology — difliculties which we have no expectation 
of removing ; nor can we hope materially to add 
to the information which is already before the 
public relative to the method of treating epilepsy \ 
but we are willing to put our mite into this trea- 
sury of medical lore: and being persuaded that 
those who arc afflicted with epilepsy may often 
be made less wretched, by rendering its paroxysm* 
less frequent, even when the patient cannot be 
perfectly cured, we willingly avail ourselves of the 
present opportunity of urging physicians to re- 
consider this disease with care, and no longer, as 
many of their brethren have done, to pronounce 



76 



EPILEPSY, 



epilepsy, when unaccompanied with iluforniiu^ of 
the cranium or imbecility of mind, incurable, un- 
til, first, they shall have endeavoured to correct in 
the patient every function which is disordered, 
and until, secondly, they shall have exhausted the 
whole armoury of the em[)iric. 

Indeed, it would seem that all those diseases 
which have been termed opprohria medicinse 
ought to be revised with care, were it only to seek 
for new and more effectual palliatives. Every year, 
by the industry and ingenuity of the naturalist, 
the chemist, and the mechanist, new agents or 
more refined expedients are discovered for abatniy: 
the discomforts caused by infirmity and pain ; and 
nothing is more conmiendaUle in a physician than 
being familiar with all those resources of art by 
which incurable diseases can be alleviated. The 
euthanasia is a subject worthy of increased atten- 
tion. The name of Ferriar, who wrote a paper 
on the treatment of the dying, ought never to be 
mentioned without an honourable addition, on ac- 
count of the humanity which guided his pen upon 
that occasion. 

There exists yet another reason whj' epilepsy 
should be investigated with renewed attention. 
This disease has often brought candour and cun- 
ning, science and ignorance, into conflict: in the 
treatment of epilepsy, the empiric, ignorant and 
bold, and often confident in proportion to his igno- 
rance, is, in the estimation of the world, superior 
to the physician who is influenced by true princi- 
ples of science and morality. The physician ought 
to use all proper means of preserving epileptics 
from falling into the hands of the designing, whose 
nets are ever extended to catch the unwary. He 
ought to avail himself not merely of science and 
observation, of the advantage which he obtains 
from being enabled to prognosticate where an ig- 
norant person can only guess, but also of prudent 
reserve, time, and favourable contingencies ; * and 
he ought not to forget that epilepsy will ofien 
spontaneously terminate, which favourable termi- 
nation nine-tenths of the community, educated 
and uneducated, patients and their friends, in s])ite 
of a disclaimer on his part, will attribute to the 
last medicine prescribed, according to that esta- 
blished aphorism of popular wisdom, post hoc, 
ergo propttr hoc. 

Epilepsy, fCT'Xfcit?, (from h( and y^aji^dvzc&ai,') 
so termed from the suddenness of the seizure. 

Synonyms. Morbus divinus, M. hercukus, 
M. sacer, M. comitialis, M. caducus, falling sick- 
ness, rnal endue, &c. Many of these appellations 
prove the dismay with which the spectator is af- 
fected upon witnessing this frightful disease. 
When a person, with whom, perhaps, one was 
engaged in agreeable conversation, and who ajjpa- 
rently was in perfect health, suddenly losing all 
sense, is thrown down and reduced in appearance 
to a state of hopeless agony, it is not wonderful 
that, in the day s of i gnorance, general amazement 

* Tlie following are instances of these contineencies 
Puer decern annoruni, jam a tribus annis epilcpticiis' 
friisira adiiiliitis iniiltis, remrdiis, corripitiir febre, epi- 
deniica. pluribiis molestiri syinptomatibus stipata et f6li- 
citer siiperat hunc morbum, et postea ab epilepsia ini- 
miinis inanet. Miscell. Cur. Dhc. iii. Ann. 7 and 8 p. 
296. Fuere qiiibns excilatus ninrbns, et nijtriins opipara 
ac desidiosa vita, subita fi<rlunariiin jactura per oninem 
vil.'am, baud conteninenda plane conipensatione, silue- 
r\' t»e Haen, pars V. Rationis Med. cap. V. 



should have been the consequence ; nor that, du. 
iiig the reign of superstition, the frij-rhtful scream 
and struggle of epilepsy should seem to argue the 
interposition of an offended deity, in this cmi^ha- 
tic manner testifying disapi)robation of passing 
events. Thus did the most politic nation of an- 
tiquity interpret the occurrence of epilepsy during 
public business, nor did they hesitate to dissolve 
a meeting the moment that so apparently porten- 
tous an eruption took place. 

Even now, when the mind is strengthened by 
true religion, which, by calming the spirit, adds 
to the powers of observation and of reasoning, 
and is destructive of superstition, and which, 
moreover, imparts just views of the divine govern- 
ment, the occurrence of epilepsy is productive of 
awe in those who are gifted with reflection ; not 
as manifesting any disturbance in the established 
order of nature, but as a striking and salutary 
evidence of the uncertainty of health, a gift gene- 
rally prized by mankind above ail others. 

Paroxysm. — The scream with which epilepsy 
usually commences is one of the most startling 
sounds that can be uttered. In female auditors it 
has produced an hysteric fit, abortion, or as it has 
been said, eclampsia. We have known it pro- 
duce in an animal an effect which, although not 
without something ludicrous in its nature, is cal- 
culated to exemplify its astounding harshness. A 
young lady, while in the drawing-room of an 
eminent phjsician, waiting the assembling of a 
consultation summoned to consider her case, was 
suddenly attacked with epilepsy. She uttered a 
scream so piercing, that a parrot, himself no 
mean performer in discords, dropped from his 
perch, seemingly frightened to death by the appal- 
ling sound. 

When, horror-struck by the scream, we turn 
to the patient, we often find him labouring under 
a general spasm, more especially of the extensor 
muscles ; his eyes may be discovered fixed and 
staring, his eye-brows contracted and lowering ; 
he appears to draw back from the beholder with 
a fixed and threatening look, which, however, it 
immediately becomes apparent, is but a senseless 
gaze. The complexion in some epileptics is leaden, 
in others it is flushed even to duskiness ; the mus- 
cles are in alternate relaxation and vehement con- 
traction, the spasms being what are called clonic. 
In a girl who was for some time under our care, 
so violent were the muscular contractions, that 
her arm was found dislocated after every fit, until, 
by a proper bandage, which she always afterwards 
wore, this accident was prevented. Burserius 
describes a similar accident, and tells us that he 
once attended a young lady whose jaw was found 
dislocated at the end of a paroxysm ; and several 
authors have observed the teeth fractured by the 
violent contraction of the muscles which elevate 
the jaw ; the tongue is often protruded, and is 
then almost always bitten, sometimes nearly 
through ; frequently the sides of the tongue, aftei 
the fit, are found ragged and bleeding, having been 
gnawed by the teeth ; from the wound in the 
tongue, the frothy saliva which is forced from the 
mouth IS often tinged with blood ; the neck ap- 
pears swollen ; the eyes roll, or are fixed in a hide- 
ous squmt, which sometimes continues after the 
paroxysm is over, and even has been perma- 



EPILEPSY. 



77 



nent ;* rapid nictitation takes place, and the mouth 
is sometimes strangely distorted. The abdomen is 
distended with flatus productive of borboi-ygmi. 
The diaphragm, abdominal muscles, and muscu- 
lar coat of the bladder, overcoming the resistance 
of the sphincters, expel the faces and urine with 
violence, nor is a discharge from the vesiculm 
seminalcs uncommon. The pulse is rapid espe- 
cially at first, but varies much ; it is generally 
full and strong towards the end of the fit, when 
sweat flows, especially from the head and neck. 
The breathing also varies ; sometimes it is sibi- 
lous, sometimes stertorous ; sometimes the lips are 
puflbd out by every expiration ; at last the breath- 
ing becomes full and uniform. The violence of 
the convulsions gradually abates, and the strong 
muscular contractions give way to subsultus ten- 
dinum ; and at last the patient, perhaps previously 
heaving a sigh, is restored to a degree of recollec- 
tion ; soon after which, exhausted by the violence 
of the struggle, he drops into a profound sleep, 
from which he awakes unconscious of his illness, 
unless admonished of having had an attack by a 
severe headach ; by the state of the tongue ; by 
discovering that there has been some involuntary 
discharge, which experience has taught him to 
connect with the fits to which he is subject ; by 
extreme exhaustion, which may continue for seve- 
ral days ; or by discoloration of the skin from 
ecchymosis similar to that which often occurs in 
hooping-cough. 

Death has taken place unexpectedly in a pa- 
roxysm of epilepsy, occasioned, as it is thought, 
b}' respiration being suspended by spasm of the 
glottis, or by congestion of the vessels of the 
brain. [This, however, is not common.] 

The attacks of epilepsy are not always attend- 
ed with so horrible a struggle as that which we 
have described. Sometimes the patient is seized 
with sickness or great faintness ; his sight becomes 
dim and uncertain, and recollection is lost, toge- 
ther with all muscular power, so that he slips from 
his chair or falls from his horse, and when his 
friends run to his assistance, they find him pale 
and bedewed with cold perspiration, perhaps in- 
sensible, but not convulsed. Occasionally he ob- 
tains great relief from vomiting ; but generally 
he continues sick, languid, and confused during 
the remainder of the day. These attacks may 
often be traced to indigestion, and sometimes re- 
quire nothing more for their removal than atten- 
tion to the state of the stomach. 

There is yet a slighter paroxysm to be described, 
indeed so slight that its nature is generally over- 
looked by the patient and his friends. It takes 
place thus : the eyes of the patient suddenly be- 
come fixed and vacant : if he be in conversation, 
sometimes he tries to prolong it in a slow, mono- 
tonous, gibbering manner. This attempt, narrowly 
scrutinized, would seem merely an abortive eflort 
to articulate the last word which he had uttered, 
and which he mumbles for half a minute or a 
minute, and then recovering, he takes up the 
thread of his discourse, being soon aware of an 
interruption of consciousness, which interruption 

* Oculorum bulbos incredibili celeritate sub palpebris 
claiisis rotari observatur, iinde in iiuisciilis oculorum 
inoveutibus ina^iia distraetio fit.ct incurabilessa;pe tola 
>rita oculorum distorsiones nianent. V. Swielen Coram. 
§ 1077. 



we have sometimes seen an artful attempt to con. 
ceal. Some individuals have described this state 
as one of great mental distress, of perplexity and 
depression, like a frightful dream ; they have an 
imperfect reminiscence of some overwhelming 
calamity, or a sense of remorse for which they 
cannot assign a cause. This paroxysm is like a 
short mood of extreme melancholy, at least such an 
impression the countenance of the patient, which 
is full of sadness, makes upon the spectator. The 
returns of these attacks are frequent ; they occur 
several times a day with some. They who are 
thus affected seldom escape for many days. That 
this slight and transient attack, which has been 
called by some French writers " vertige epilep- 
tique," is truly an epileptic paroxysm, we are of 
opinion, from having observed the chain of thought 
completely broken ; from having seen it in per- 
sons who had been affected with falling sickness 
in its severest form ; from having known falling 
sickness aflect patients who had suffered under 
these slighter fits, and from a recollection of the 
slighter and more severe attacks being alternate in 
the same individual. This alfection is alluded to 
by Burserius, (Burscrius, vol. iv. § 264,) as well 
as certain other attacks, in which a clonic spasm 
of only some parts, as of an arm or only of the 
face, takes place, or in which all the senses are 
not overwhelmed, in the following terms : " There 
are, moreover, certain degrees of approximation 
to epilepsy in which the senses are interrupted 
only for a niomrnt, and scarcely any convulsive 
motion, or only a very slight one, takes place, the 
patient not falling to the ground, but continuing 
to stand. These I should rather name epileptic 
attacks than actual ^^pilepsy. But if they are ne- 
glected, a transition first toenilepsy, and next to that 
which is severe and perfect in general gradually 
takes place." Heberden briefly describes this alfec- 
tion as follows : " Postremo animte defectio levis, 
quae modo antecedit justam epilepsiam, modo quasi 
vicem ejus implet, dum nihil aiiud seger sentit 
praster oblivium quoddani, et delirium adeo breve 
ut fere ad se redeat priusquam ab adstantibus ani- 
madvertatur." (Heberden, Comm. cap. xxxiii.) 

The following case of this sub-epileptic seizure 
was written by the patient herself, (C. S. set. 37,) 
and is highly illustrative. " Even when a girl, I 
was very nervous, sometimes losing all my strength. 
I have also been liable to a complaint in my 
liver, for which I was rubbed with mercury. I 
have had working and uneasiness in my feet, 
which was quite painful. Now, at times while 
speaking, or while any one is speaking to me, I 
get a confusion on the subject about which we 
are conversing, which used to last for some time, 
but does not now for more than a minute, and 
when it is gone I have a most violent palpitation. 
I have it now much oftener, but it does not last 
so long. I am told I grow pale round mv mouth 
and look rather melancholy for the time, and fix 
my eyes upon the person with whom I have been 
talking. I at the same time work my hands, from 
having a most uncomfortable feeling in them. I 
am told I always make a noise in my throat, and 
moan ; but of this I am not conscious, and I seem 
to be in a tremble, my hands shaking. I ain tor- 
mented with a pain which goes from my chest to 
my back-bone, and prevents me from drawing inv 



78 



EPILEPSY 



breath, and gives mc an inclination to sigh. From 
my head K- my fi-et I am at times in pain, and I 
feel as if there were a heart be-itinj in every part 
of my body. A numbness comes in my hands, 
particularly at night, and then I have no feeling 
in my Angers, till by rubbing I get it back. Ocea- 
sionally I have had numbness and coldness in my 
tongue. A lump came in the outside of my throat, 
which often returns with violent throbbing. This 
I have every evening."* In this patient there 
was great irregularity in the uterine function. In 
truth, this was a specimen of uterine epilepsy in- 
termingled with hysteria, which was aggravated 
by continued anxiety of mind and a diet much too 
stimulating. 

In the much greater number of patients parox- 
}'sm of ejjilepsy occurs without warning,-}- but some 
are admonished of its approach by symptoms rc- 
ferrible to a disturbed state of the brain or of the 
external senses, similar to those which are premo- 
nitory of apoplexy ; as for instance, excitement of 
the mind ; throbbing in the temples ; turgescence 
of the veins of the neck ; flushing of the face, with 
cold extremities ; giddiness, weight, headach, drow- 
siness, forgetfulness ; disturbed rest, frightful 
dreams ; irritability of temper, despondency ; in- 
articulate speech ; flashes of light or sparks of fire 
seen in the dark ; tadpoles, motes, flies, chains, 
or cobwebs, appearing before the eyes ; coloured 
areolae around the candle, or any other luminous 
body ; dimness of sight, or, only one portion of an 
object distinctly visible ; hissing, ringing of bells, 
roaring of the sea, or other discordant noises 
heard ; strange and unpleasant odours smelt ; dis- 
agreeable tastes occurring ; numbness in the course 
of a nerve, or tremblings or convulsions in a limb 
mounting upwards. Watching or delirium some- 
times precede a fit, during which ghosts and appa- 
ritions are supposed to appear; and as the fit does 
not always follow the illusion, many of our ghost 
stories and supposed visions doubtless have arisen 
from threatenings of epilepsy or of apoplexy. We 
knew an individual subject to epilepsy who be- 
lieved that his mother had visited him after her 
death. Disorders of the digestive organs fre- 
quently precede epilepsy, as pain in the abdomen, 
salivation, sickness, vomiting, looseness. Some- 
times the paroxysm follows hysteric symptoms, 
sometimes obstructed or painful menstruation ; 
or, lastly, the attack follows the aura epileptica, 
which is a sensation as if a current of air, stream 
of water, or slight convulsive tremor ascended from 
a part of the body, or of the extremities to the 
head ; when the aura reaches the head, the patient 
falls dowTi in convulsions. This sensation has 
first been felt in, and seemingly has arisen from, 
various parts of the body ; from the toe, foot, leg, 
groin ; from the finger, hand, arm ; from the bot- 
tom of the spine, uterus, loins, abdomen, and 
chest. 

* Perhaps we may be allowed to observe that a swell- 
ing of the thyroid gland, which is often a symptani of 
hysteria, has not, as far as we know, been sufficiently 
attended to. 'Jliis swelling sometimes disappears and 
returns, but is more conunonly permanent ; in its ex- 
•ernal character it is not dislinguishat)le from broncho- 
cele. 

t Sur cent malades, on en trouve a peine quatre ou 
cniij tlont les aitaques soient pretedees<t ariiioncccs par 
des symptom(?s precurseurs. Chez les qnatre vinL't qiiinze, 
'III qualru vingt seize autres, rinvasion de I'aitaque e!?t 
moite. Gcorget, Did. de Medecine, Art, F.jiileysie. 



Here wc would observe, that the epileptic fit 
does not always take place when the patient is 
thus menaced with it [and, very frequently, it is 
wholly absent]. Premonitory symptoms of epi- 
lepsy often occur; not only vertigo, headach, false 
perceptions, but convulsions in a limb, or in one 
side of the face, similar to those spasms to which 
Burserius alludes, with weakness, headach, and a 
degree of stupor; after which the patient recovers, 
without the convulsions becoming universal, or 
insensibihty being complete. Dr. Prichard con- 
siders these as attacks of partial epilepsy, under 
which head they are described by that eminent 
pathologist. To us it would rather appear that, 
like the aura, they are mere threatenings of a fit. 

In some patients epilepsy is congenitc, in others 
it commences in childhood, in others in youth, 
manhood, and even in age. Sometimes, when 
previously established, it subsides at puberty ; and 
sometimes, especially in females, the disease com- 
mences at that important epoch. There is much 
variety and uncertainty with respect to the return 
of the paroxysms. The attacks have been peri- 
odic, but much more generally they are irregular 
in their recurrence. Months, nay years, may in- 
tervene between the severer attacks ; while the 
slighter may return daily .-(- We have preserved 
no list of the epileptic patients by whom we have 
been consulted, and cannot state the proportion of 
males to females, but our impression is that we 
have seen many more of the former than of the 
latter ; hence the oliservation of Heberden, distin- 
guished for his accuracy, is, we presume, true with 
respect to epilepsy as it occurs in the upper and 
middle ranks of society, " Feminae tamen rarius 
quam viri in earn incidunt." (Heberden, Comm. 
cap. xxxiii.) 

We have known individuals subject to epilepsy 
preserve their intellect unimpaired in old age. A 
very dear friend who was liable to epilepsy, died 
a few months ago in the seventy-fourth year of 
his age, whose comprehensive, well-st(n-ed, and 
active mind rcm.ained unclouded till within a few 
weeks of his death. But it is often otherwise ; 
many become corpulent, indolent, dyspeptic; 
others are aflected v^ith paralysis, apoplexy, or 
veternus, or sustain gradual inroads on the intel- 
lect, which lead to amentia, the relations of things 
being no longer perceived or recollected by them : 
like mere machines, they act as they are induced 
to do by external influence; no longer able to 
originate anything, when they receive an impulse 
they are carried on as it were by mere habitual 
training, the power of modifying their conduct by 
circumstances as they arise being lost. They 
generally sit all day long staring and drivelling, 
inattentive to the calls of nature ; so that at last 
their most sanguine and aflectionate relatives, des- 
pairing of their recovery, become anxious for their 
death as a release from suffering and degradation. 
The change which takes place in tiie c^xpression 
of the countenance cannot be better described than 
in the words of M. Esquirol. " Les traits de la 
face grossissent, les paupieres infc-rieures se gon- 
flent, les l^vres deviennent epaisses ; les plus iolies 
visages enlaidissent, il y a dans le regard quclque 

t Heberden relates a case in which therp wa« an in 
lerval of thirlt-en years bciwccn the first ami second 
paroxysm. ' N»^«"m 



EPILEPSY. 



79 



chose d'egare, les yeux sont vacillans, les pupiles 
dilatees. On voit souvent des mouvemcns con- 
vulsifs de quelques muscles de la face." (Diction. 
desSciencesMcd. vol. XV. Art Epikpsie'). While 
we transcribe from Dr. Cooke's valuable work on 
nervous diseases the following descriptive passage 
from Aretacus, we would have the reader take note 
that it is applicable chiefly to the extreme cases 
of the epilepsia cercbralis. " If the disease be of 
long duration, patients suffer from it even in the 
intervals of the paroxysms; they become torpid, 
languid, and dejected ; they avoid the sight and 
society of men ; time does not afford any mitiga- 
tion of their sufferings ; they are often oppressed 
with watchfulness, and when they do sleep they 
are terrified with horrible dreams ; they loathe 
food, and digest with difficulty ; their natural co- 
lour disappears, and changes to a leaden hue ; 
they have a difficulty of comprehension on account 
of torpor of mind and of sense ; they are dull of 
hearing, are affected with a ringing of the ears, 
and a confused sound in the head ; the tongue is 
unable to do its office, either on account of the 
nature of the disease, or from injuries which it 
may have received in the paroxysms ; they are 
agitated by convulsions, and sometimes the mind 
is so disturbed by the complaint, that persons la- 
bouring under it become fatuous oriJiotic." (Dr. 
Cooke on Nervous Diseases, vol. ii. p. 24.) 

Species of Eitlepst. — This disease has been 
divided into the idiopathic and sympathetic spe- 
cies, the former embracing the cases which depend 
upon an affection of the brain, the latter the cases 
which depend upon an affection of parts remote 
from the brain — the epilepsia cerebralis and the 
epilepsia si/mpafhica. With respect to the epilep- 
sia occasionalis, which is the third species of 
Cullen, most of its specimens may he considered 
merely as convulsions symptomatic of other dis- 
eases. Thus the epilepsia traumatica, e veneno, e 
scabie rclropulsa, a h^morrhagia niinia, a debilitate 
febricosa, ab hydroccphalo, &c. ought to be treated 
of under the headof wounds, poisons, &c. or if consi- 
dered not as symptomatic, they ought to rank under 
the head of eclampsia, an acute disease, of which 
the paroxysm may never be repeated, and not under 
epilepsy, which is a chronic disease and recurrent. 

It must not be denied that it is not always an 
easy matter to distinguish between the epilepsia 
cerebralis and the epilepsia sympathica : the rules 
for discriminating the one from the other, laid 
down by authors, are by no means implicitly to 
be relied upon ; and, as the decision of this point 
is not always practicable, the physician, in the 
course of an attendance, will sometimes have to 
change his opinion, for which he ought to be pre- 
pared. A dictum of the celebrated Cullen, namely, 
that in the epilepsia cerebralis there are no pre- 
monitory symptoms, while the epilepsia symathica 
is generally announced by an aura frigida, has not 
been confirmed by our observation. 

In our endeavour to determine the species to 
which a case of cpile})sy belongs, we may proceed 
as follows ; — First, we may inquire into the state 
of the natural functions — the state of the appetite, 
digestion, and nutrition, and into the condition of 
the secretions and excretions; then into the state 
of the nervous system : md lastly, if the patient 
h a female, into the functions of the uterus, espe- 



cially with respect to menstruation. If we are 
unable to detect any affection of the nerves, any 
local irritation, or disorder of a part remote from 
the brain, we may witli probability consider the 
case as a specimen of the epilepsia cerebralis. 

In this conclusion we may repose with more 
confidence, if we discover that the disease is inhe- 
rited ; that the patient has been liable to vascular 
congestion in the brain from determination of 
blood to the head, increased action in the arterial 
system within the cranium, or obstruction in the 
system of the veins, to be inferred from flushing 
of the face, throbbing in the temples, epistaxis, 
vertigo increased by stooping, dulness or weak- 
ness of intellect, tightness across the forehead, 
headach, false perceptions; that there is anything 
peculiar in the form of the head, or expression of 
the countenance ; and that the habits of the pa- 
tient have been such as to produce considerable 
or long-continued excitement of the brain. Pa- 
roxysms of epilepsy which occur late in life in 
persons who have had apoplexy, or whose diathesis 
is apoplectic ; rank under the epilepsia cerebralis ; 
as also do those cases of not unfrequent occur- 
rence, in which epilepsy almost invariably leads 
to an attack of insanity; cases which differ in two 
respects from the more common form of periodic 
insanity, 1st, in commencing with an epileptic fit ; 
and, 2dly, in tlie mind being much sooner restored 
to sanity — derangement continuing sometime" 
only for a few days. It may, however, be worth 
while to observe, that while differing in these 
respects, the mental disturbance which follows 
epilepsy, and riMnia periodica, require the same 
method of treatment. 

Of the epilepsia sympathetica there are five 
species, viz. that in which the brain sympathizes 
with a disordered state of the stomach, of the liver, 
of the nervous system, of the uterus, or with any 
part of the body suffering from pain or irritation. 
The following, then, is our arrangement of the 
subject : — 

I. Epilepsia cerebralis. 

II. Epilepsia sympathica. 



Sp. 



Epilepsia stomachica. 

— hepatica. 

— nervosa. 

— utcrina. 

— a dolore. 

\st species. — In addition to many of the com- 
mon symptoms of indigestion, sucli as a loaded 
tongue, unpleasant taste, acid or rancid eructations, 
cardialgia, heavy breath and perspiration, high- 
coloured urine, fulness of the hypochondria, and 
foul discharges from the bowels ; the appetite in 
the epilepsia stomachica is extremely irregular 
and capricious ; sometimes it is defective, often 
canine, and a sense of distension of the stomacli 
takes place after meals. Even while the demand 
for food is exorbitant, it will often lie in the sto- 
mach undigested for two or three days ; this is 
frequently the case about the time of a paroxysm, 
shortly after which we have known an enormous 
quantity of half-digested food voiuitcd, part of 
which had been eaten at least two or three days* 
before. " Epilepsia stomachica ea est quara fovel 
et cxcitat crapula ; cardialgiis, ructibus, anorexia, 
dyspepsia, nauseis, vomitione, prajgressis." Sau- 
vages, d. iv. cr. xix. 



PO 



2d species. — The liver more than the stomach 
would sometimes appear to be the organ in which 
this disease originates. Cases have been reported 
to us in which paroxysms of epilepsy were inva- 
riably preceded by change in the complexion, and 
pain and tenderness of the right hypochondrium ; 
and in which by great attention to the liver, when 
its function became disturbed, attacks of epilepsy 
have been averted. We learn from Burserius, 
that, in certain cases, epilepsy is preceded by pain 
in the region of the liver, icterus, and symptoms 
of calculi in the gall-bladder ; and from Dr. 
Prichard, that he has witnessed several cases of 
epilepsy wherein the symptoms which point out 
the existence of chronic diseases of the liver were 
clearly discernible. The following is a brief case 
of the epilepsia hepatica. 

" May 6, 1 S27. Mr. , of a highly scro- 
fulous diathesis, has been affected with epilepsy 
for several years. The fits commenced at the age 
of thirteen, and were for some time very frequent 
in their recurrence ; what remedies were employed 
at first does not appear, but of late he has tried a 
variety of quack medicines. About twelve months 
ago, after a rapid succession of paroxysms, he 
consulted Dr. Casey, of Cork, who found him 
complaining of pain and soreness in the right 
hypochondrium, his complexion being at the same 
time sallow, and his stomach disordered, and by 
whom small doses of a mercurial medicine and 
bitters were prescribed, by means of which these 
symptoms were removed, and there was no return 
of epilepsy for some months ; after which, in 
November, symptoms of great hepatic disorder 
returned, of which two paroxysms of epilepsy ap- 
parently were the consequence. Since which he 
has had no paroxysm in a perfect form ; but he 
has experienced symptoms wliich formerly had 
forewarned him of an attack, and which he de- 
signated a " nervousness," namely a sudden tre- 
mor with a momentary but slight convulsion, at 
which time there was always more or less disorder 
of the hepatic function ; when these symptoms 
occurred, a brisk mercurial purgative was given, 
and under this simple treatment he has enjoyed a 
longer exemption from convulsions than since the 
commencement of his illness." 

3d species. — In pursuing our investigation, we 
ought next to endeavour to ascertain whether the 
patient, if a female, is labouring or has laboured 
under hysteria; whether she has been liable to 
rapid palpitation of the heart, sudden failure of 
strength, faintings without loss of consciousness, 
entire loss of voice, anorexia, or any of the more 
palpable symptoms of hysteria, as the globus or 
cluvus hystericus. Nay, although there be no 
symptoms of hysteria, causes which produce that 
afTection may have been in operation prior to an 
attack of epilepsy, as sedentary occupation in a 
close and cold apartment, insufficient food, de- 
pressing passions ; and if so much light may be 
thrown on the case, through a knowledge of the 
iliathesis of the patient. Nor ought the inquiry 
respecting the symptoms which characterize hys- 
teria to be confined to the female ; for symptoms 
which no one would hesitate to call hysterical, if 
occurring in a female, may frequently be detected 



EPILEPSY. 

^e may include both .sexes, this species ought to 
be called epilepsia nervosa rather iban epilepsia 
hysterica, hitherto the term which has been ap. 
plied to it. 

In patients liable to epilepsia nervosa, there 
may sometimes be observed preceding a paroxysm, 
an excessive irritability with jactitation, weakness, 
tendency to deliquium, susi)irious breathing re- 
quiring a constant supply of fresh air ; or tinni- 
tus aurium, vertigo, and the wildest hysteric de- 
lirium. 

4M species. — .\n inquiry into the condition of 
the uterine function will sometimes discover the 
nature of an attack of epilepsy, which may lie 
connected with obstructed menstruation or dys- 
menorrhcea. The epilepsia uterina arises and re- 
turns at or about the period of menstruation; 
sometimes for the first time at puberty, and often 
in consequence of those causes which check men- 
struation, as damp and cold feet, excessive fatigue, 
great anxiety of mind, or alarm. In our opinion 
this species ought to stand apart from the third 
species, with which it is generally identified, but 
from which it differs both in its causes, exciting 
and predisponent, and in the method of treatment 
which it requires. 

5th species. — To this species of the disease be- 
long cases of epilepsy originating in injuries, in 
which the nerves are wounded or lacerated, or 
arising from diseases of the nerves. In the Edin- 
burgh Medical Essays and Observations, (vol. iv. 
art. 27,) a case of this nature is related, in which 
epilepsy^ was caused by a cartilaginous tumour of 
the size of a large pea, which was situated on a 
nerve. Upon the excision of the tumour the fits 
ceased. In the same work there is an account of 
convulsions being caused by a concretion of the 
size of a nut pressing upon a branch of the sciatic 
nerve. One such neuralgic affection we have 
witnessed, but we rather think the convulsions in 
that case were not strictly epileptic. To this spe- 
cies, also, belong the affections described by La 
Motte, in which epilepsy was caused by calculus 
in the pelvis of the kidney : one epileptic, after a 
violent paroxysm of the disease, voided five cal- 
culi, and had no return of the fits. (Vol. ii. p. 20.) 
As these cases, however, are rather within the 
province of the surgeon, we shall not revert to this 
species of the disease when we come to explain 
the treatment of epilepsy. 

It must be acknowledged that the symptom* 
which, in distinct groups, give a specific character 
to a case of epilepsy, are in some instances con- 
fusedly intermingled, whereby the symmetry of 
our attempted arrangement is disturbed, and what 
is of much more moment, the remedial p\ocess 
rendered difficult by contra-indications : thus it 
would not be easy to say to which of the forego- 
ing varieties the following case belongs, which is 
presented, not to discourage the student, who «ith 
increasing experience will see more clearly that 
our division of this important subject is founded 
on just observation, but to show him that theif 
are difficulties which it will require persevering 
study as well as the most attentive observation to 
conquer. 

I r^"/^,^J^^u"u^".'^ of harvest, 1829. a young 
lady, xt. 17, who had not begun to menstruate, of 



in males subject to epilepsy, who are of a nervous 

temperament or hypochondriacal ; and hence, that I a very strumous habit,' and^^y^hTfRkt^'wiA 



EPILEPSY, 



81 



psoriasis laliialis, having a dry, scabrous, branny 
rikin, and bcinjT liable to hysteria in an aggravated 
form, was visited for the first time by a physician 
just as she was recovering from a paroxysm of 
epilepsy, several attacks of which she has since 
had at the intervals of one, two, or three months. 
After the first attack there was a sense of fulness 
and tension in the head, with symptoms of hepa- 
tic congestion and torpor, all of which yielded to 
a moderate bleeding from the arm, together with 
the use of calomel and pulvis Jacobi, followed by 
a draught of the infusion of senna and the com- 
pound decoction of aloes ; and subsequently the 
shower-bath, and diet of easily digestible materials, 
together with tonic medicines. Her tongue had 
usually been coated, the digestive function deprav- 
ed, as appeared from anorexia and a very capri- 
cious choice of food ; the alimentary canal very 
torpid, requiring the continued use of various ac- 
tive purgative medicines. The paroxysms appear- 
ed some of them to be averted by a pill of calomel 
over night and a purgative draught in the morn- 
ing, so that indigestion seemed to be the chief ra- 
dix niorbi." 

Pathology of Epilepsy. — That there will in 
general be found, on dissecting the bodies of those 
who have laboured under falling sickness, some 
exemplification of diseased structure in the cra- 
nium, subjacent membranes, cerebrum, cerebel- 
lum, or sjjinal canal, works of morbid anatomy, 
and treatises on epilepsy, have taught us to expect ; 
they show that after death we may count upon 
finding a part of the contents of the cranium 
affected through the operation of some irritating 
cause. In some dissections is discovered exosto- 
sis, or thickening of the bone, which indeed may 
be a consequence rather than a cause of disease ; 
in others, inflammation or ulceration of the mem- 
branes of the brain, of its surface or substance ; in 
others vascular turgescence ; effusion of various 
fluids — bloody, serous, gelatinous, purulent ; in- 
duration or softening of the brain ; tumours some- 
times arc detected, whether scirrhous, fatty, or 
sarcomatous ; and lastly, tubercles or hydatids : 
but what may be disclosed by any one dissection 
about to be performed, whether an appearance 
connected with some change in the structure of 
the bone, membranes, or the brain itself; nay, 
whether any morbid change will be discovered, a 
cautious physician would not venture to predicate. 
The following is one of many quotations which 
we might produce to show that dissection hitherto 
has given us but little aid in ascertaining the 
cause of epilepsy : " Sed et fessi fuerent summi 
in arte viri, atque in rebus anatomicis peritissimi, 
quod in cadaveribus hoc morbo defunctorum nihil 
invenerint sjepe quod culpare poterant." (Van 
Swieten, Com. s. 1872.) 

Even the brothers Wenzel, who have produced 
a monograph on this subject of the highest order, 
in which we recognize just principles of investi- 
gation, ability, and zeal, after an inquiry continu- 
ed for a good many years, and the careful dissec- 
tion of above twenty ejuleptics, confining their 
observations to idiopathic epilepsy, to the exclu- 
sion of those cases, " en qui cette maladie pent 
el re produite par des vers ou attires causes exte- 
rieurfi et materielles" and arriving at a conclu- 
sion that the disease is seated in the sphenoidal 
Vol. II.— 11 



bone, in the pineal gland, and the pituitary gland, 
but chiefly in the latter, have added but little to 
the pathology of epilepsy. 

Admitting their conclusions to be just, it will 
not satisfactorily explain the nature of the disease, 
nor lead to any practical improvement, the great 
objects to be obtained from the cultivation of mor- 
bid anatomy. There seems to have been the 
greatest diversity in the appearance and condition 
of the pituitary gland.* Its colour was not uni- 
form, nor yet was its consistence. In some cases 
it was very soft, and in others preternaturally 
hard ; and in respect of its size and structure 
there was also great diversity. The Wenzels, we 
conceive, have merely opened up a new path — a 
path which ought to be explored by future inqui- 
rers notwithstanding the discouraging remark of 
M. Esquirol, " de toutes ces recherches, particu- 
lierement de celles de Bonet, de Morgagni, Bailie, 
Greding, Meckel, Wenzel, que pouvons-nous con- 
clure i" Rien, sinon que ces niemes alterations 
ont lieu ches des individus qui ne sont pas 
epileptiques, comme Wepfer, Lorry I'ont prouve. 
Avouons franchement que les travaux de I'anato- 
mie pathologique n'ont jusqu'ici repandu aucune 



* As it would appear from a paper placed in our hands 
by Dr. Tweedie, which was written by his friend Dr. 
Sims, of London, that in the French Translation of the 
work of the Wenzels by M. Breton, ann. 1811, the Ger- 
man word hirnanhang, which ought to have been trans- 
lated gland pituitaire, has been rendered cervelet, we are 
induced to lay before the reader in this note an extract 
from Dr. Sims'spaper, in which an accurate account is 
given of the labours of the German patliologists. 

"The Wenzels regard as a patlinlogical circumstance 
a peculiar thinness of the sphenoidal bone and of this 
part of the base of the skull, when compared with the 
ordinary thickness of the other bones; variations in the 
position, curvature, and size of the clynoid apophyses; 
which destroy the natural symmetry of the l)ones of tlie 
basis, and occasion changes in the capacity and form 
of the sella turcia. These have an influence on the 
brain and pituitary gland. 

"The pineal gland, in several cases, was altered in 
colour; in ten it was a pale grey ; a brownish yellow 
vesicle on its upper surface is noticed; in all it was 
softened ; in nine it was much smaller, in two much 
larger than natural. 

■' In the pituitary gland the principal changes were 
observed, some of which certainly would require the 
close inspection of a practised eye to discover : an une- 
qual and furrowed appearance of the upper surface— in 
two instances a muscular ajipearance as in old people; 
excavations, or loss of substance of the upper surface; 
depression along the anterior margin ; alterations of 
colour, as various shades of red verging to black, pale 
grey, yellow, brownish yellow, and pale white. In three 
cases it was very soft ; in five, firm, compact, and of un- 
natural hardness, considerably enlarged, with an effu- 
sion of thick lymph between the two lobes. In seven 
of prodigious size. The most important alterations ex- 
isted in the interior: in ten cases, at the point of union 
of the two lobes, there was a yellow, solid, friable mat- 
ter, which might be raised in bits ; this substance almost 
always (independent of the separation of the lobes) oc 
casioned a loss of substance. In five cases there was a 
viscid semifluid lymph between the two lobes. Patches 
of white, or brownish solid lymph on the superior sur- 
face of the gland ; the anterior lobe enlarged, and con- 
taining a substance resembling pus; the lobes joined 
without intermediate surface ; the lobes separated from 
each other, the upper surface inflamed. 

" In some instances the infundibulum was firmer than 
natural ; in one instance an eftiision of lymph resem 
bling false membrane was deposited around a portion of 
it; in another part it was red and inflamed. 

"Several other morbid appearances are noticed. Ex 
crescences on different parts of the basisof the cranium 
caries of the bones; effusion on the internal surface of 
the dura mater, and on the arachnoid lining; varia 
tions of the convolutions of the brain, of its magnitudt 
and colour; in the ventricles, corpora striata, thalami 
nervorum opticorum, tubercula quadrigemina. In fifteen 
of the dissections, the cerebrum and cerebellum weie 
perfectly healthy. 



lumiere sur le siege immediat de I'epilepsie. 
(Diction, des Sciences Medicales, Art. Epilepsie.) 

[Recent writers — MM. Bonchet and Cazau- 
vielh— whilst they accord with MM. Forille and 
Delage in their view, that mania consists in acute 
or chronic inflammation of the cortical substance 
of the brain, are of opinion, that epilepsy consists 
in chronic inflammation of the medullary neurine.] 

Proximate Cause* — Nothing can be more 
obscure than the proximate cause of this disease. 
As convulsions similar to those which attend epi- 
lepsy may be produced by the application of an 
irritant direct to the brain ; as every part of the 
frame is agitated during a paroxysm — all the ex- 
ternal senses often being morbidly affected just 
before the paroxysm, the whole muscular system 
agitated during it ; and as not only the animal but 
the vital functions are universally perturbed, the 
proximate cause must be seated in the sensorium 
commune, as being the only part capable of exer- 
cising such an influence over the whole body ; but 
the nature of the disorder upon which the epilep- 
tic fit depends will probably never be discovered. 
It cannot be vascular distension, since convulsions 
are often a consequence of loss of blood, (no other 
cause at the same time operating,) and may be 
removed by stimulants. It cannot be vascular 
collapse, since convulsions sometimes depend upon 
plethora, and are relieved by spontaneous hemor- 
rhage or by bloodletting. 

In this disease we are unable to lay hold of the 
first link in the morbid catenation. It is generally 
thought that the aura epileptica is an irritation 
which first takes place in the sentient extremity 
of a nerve, and is thence conveyed along the af- 
fected nerve to the sensorium, which is thus 
thrown into disturbed and irregular action, influ- 
encing the whole body ; but to us it would appear 
that the aura epileptica is not an irritation of a 
nerve in the part from which it seems to arise, for 
then it would take the course of the nerve instead 
of passing along the integuments ; but that it is a 
reflex sensation, caused by a morbid process going 
forwards in the brain, or a part of it — that it is a 
false perception — a mere symptom of an unex- 
plained disorder of the sensorium, as much as tin- 
nitus aurium, or muscae volitantes, or numbness 
in a nerve, or pins and needles, as a certain prick- 
ling sensation is called by paralytic patients. It 
would be vain to investigate the essence of a dis- 
ease, in which there is the utmost uncertainty even 
in the first stage of our inquiry ; in which dissec- 
tion, instead of affordinT assistance, rather per- 
plexes us by the multiplicity and diversity of the 
changes of structure which it discloses. Moreover 
it virould appear that so long as we are ignorant 
of the nature of the healthy function of the brain, 
in what manner its influence over the body arises 
and is maintained, the deviation from the healthy 
exercise of its function which constitutes the proxi- 
mate cause of epilepsy must remain sub judice. 

Preclisponent Cause. — According to sys- 
tematic writers, the pre(lis|)osition to epilepsy is 
supposed to depend on " great mobility," on " a 
peculiar liability to excitement and collapse;" on 
■' a liability to be influenced by those causes which 
are applied to most persons with little or no ef- 
fect." This condition connected with " a greater 
:legree either of sensibility or irritability, it is con- 



E PILE PS Y. 

"~^ived, is generally derived from original stamins 
an<i may more particularly depend cither upon 



debility or upon a plethoric state of the system." 
We must, however, observe that we have known 
epileptics, who did not give way to strong emo- 
tions upon slight impressions, who were with dif- 
ficulty excited, and who jjursued every purpose 
with a manly constancy ; and hence, without de- 
nying that a state, not easily definable, of mobili- 
ty, is a predisposing cause of epilepsy, we con- 
ceive that it is by no means the only predisponcnt 
to that disease. An opinion on this subject which 
we hold, we think will probably not obtain favour; 
and yet, as it has not been hastily formed, we con- 
sider it a duty to put it forward, that it may be 
verified or disproved by future observers. We 
conceive that epilepsy is as certain a manifestation 
of the strumous diathesis as tubercular consump 
tion, psoas abscess, hereditary insanity, or certain 
congenital malformations or defects of organization 
which are inherited only from scrofulous parents. 
Epileptic patients are of the habit of body in which 
scrofula occurs. We have no recollection of a 
case of cerebral epilepsy in a patient, who, when 
due inquiry was made, did not appear to mherit a 
strong disposition to scrofula. It must be admit- 
ted, however, that there are many epileptics in 
whom there exist none of the more common 
symptoms of scrofula. 

That epilepsy is a hereditary disease is gene- 
rally admitted. If, when consulted by an epilep- 
tic, we make dihgent inquiry, we shall find that, 
although direct progenitors, father or mother, may 
have escaped, yet some member of the family 
(uncle or aunt, grandfather or grandmother,) has 
been subject to fits. As Boerhaave has observed, 
" silente ssepe morbo in genitore, dum ex avo deri- 
vatur in ncpotem." If epilepsy for the first time 
occurs in a family, it has appeared to us that it 
has been in consequence of the strumous diathesis 
having been exalted by the intermarriage of two 
persons inheritors of that condition or tendency 
of the constitution, and which it has been in a yet 
more remarkable degree if the parents were of the 
same blood and nearly related — we may then ex- 
pect, if an epileptic patient has several brothers 
and sisters, that his case will not be a solitary one 
in the funnily. 

[We have no adequate statistics to enable us to 
settle the question as to the hereditary nature of 
epilepsy.] 

Occasional causes. — Patients, especially those 
who have had only two or three attacks of epi 
lepsy, are ever ready to consider them as acci- 
dental. One attack is brought on by a fright, 
probably the most frequent exciting cause of the 
disease; another by over-fatigue; one by confined 
bowels; another by a strong purgative; one by 
fasting, another by a surfeit ; and it cannot be de- 
nied that very many attacks of epilepsy mav natu- 
rally enough be traced to some inattention to the 
organs of assimilation, especially in the form of 




ture of the skull, which left a depression of the 
bone. After the accident occurred, he was sub- 
ject to epilepsy whenever he indulged in the use 
of intoxicating liquors: at last he was induced to 



EPILEPSY, 



H3 



lay them aside, and ever since he has been with- 
out an attack of epilepsy, and is now an able- 
bodied watchman. " I have observed," says Fo- 
thergill, " that epileptics are often extremely incau- 
tious with respect to diet; that children highly 
indulged are liable to the disease; that in every 
other period of juvenescence, and in middle-aged 
adults, if they were attacked with the disease, it 
was when they had cither committed some ex- 
cesses, or by one means or another were plethoric ; 
and that in habits subject to epilepsy, the disease 
seldom recurred without either an habitual indul- 
gence in eating, or a neglect of necessary exercise." 

The occasional causes of epilepsy may be divi- 
ded into two classes. 1st. Joy, anger, suppressed 
discbarges, repelled diseases, elevated temperature, 
bodily over-exertion, drunkenness, prolonged sleep, 
surtViting, congestion of the bowels, obstructed or 
painful menstruation. 2. Opposed to these are 
terror, grief, disgust, exhaustion of mind from in- 
tense application to business or study, vigilance, 
inanition, hypercatharsis, venereal excesses, he- 
morrhage. " Parmi les causes excitantes de 
I'epilepsie la frayeur tient a-coup sur le premier 
rang. La colore et un chagrin profond, la mas- 
turbation, et les execs veneriens paraissent, apres 
'a frayeur, tenir le premier rang parmi les causes 
Je Tepilepsie." (Diction, do Medecine, Art. Epi- 
lepsie.) We read of epilepsy being caused by 
imitation. An attack of epilepsy, when witnessed 
by a number of unmarried females in a church or 
school, has often led to convulsions spreading from 
one to another, till a great many are affected. 
Dr. Why tt describes this affection in the following 
words : " There is a disease very common in the 
islands of Zetland, which is known there by the 
name of the convulsive fits. It begins with a vio- 
lent palpitation of the heart ; soon after which the 
patients fall to the ground, unless they are sup- 
ported ; their arms and legs are alternately con- 
tracted and relaxed ; and in some cases their joints 
become so rigid that they cannot be bent. Their 
respiration seems to be difficult, and they cry ter- 
ribly vi'hile the fit lasts, which is generally less 
than a quarter of an hour. This disorder seldom 
attacks married women ; but young women, and 
even girls of ten or twelve years of age, are liable 
to it. Some boys and tv^'o young men in these 
islands have also been affected with it. In the 
church or other public meetings, as soon as one is 
seized, all such as have formerly been subject to 
the distemper are attacked with it, which often 
occasions great disturbance." These attacks, there 
cannot be a doubt, arc not epileptic, but, like cer- 
tain more recent exhibitions in churches, are clearly 
refcrrible to sympathetic hysteria. 

[A recent writer, M. Meyer, has published some 
cases of what he terms epidemic epilepsy, occur- 
ring in schools. In consequence of a girl being 
attacked with epilepsy, numerous others became 
affected. Most of the girls were approaching the 
age of puberty, and tliey were all of a highly ex- 
citable temperament. It is probable, indeed, as 
the writer has stated elsewhere, (^Practice of Me- 
dicine, ii. 230,) that these were cases of hysteria 
rather than of epilepsy. Many cases, however, 
are on record, in which the disease appears to have 
been produced by the sympathy of imitation from 
witnessing a paroxysm in another. 



An idea has long existed, that the paroxysms 
of epilepsy may be connected with the condition 
of the moon ; but there docs not seem to be any 
sufficient reason for this belief] 

Of the occasional causes of epilepsy, it is justly 
observed by Dr. Cooke, that " some are stimulants 
producing an increased action of the brain, while 
others are sedatives, operating so as to diminish 
its energy." When there is a predisposition to 
epilepsy, a cause of either kind, productive either 
of excessive or defective action, may interrupt the 
equable transmission of the sensorial power by 
means of the nerves, and thus occasion a fit; and 
hence it would appear desirable to retain every 
patient who is subject to epilepsy in a state equally 
distant from plethora or from undue emptiness of 
the cerebral vessels. 

[Perhaps disorders of the digestive canal, while 
a predisposition to epilepsy exists, are the most 
common exciting causes ; and, accordingly, we 
often find the paroxysms recur as certainly as ali- 
ment, improper by character or quality, is received 
into the stomach. In such case, the disease is 
" eccentric" epilepsy.] 

Diagnosis. — We have reason to think that not 
only eclampsia, but hysteria ; cataleptic hysteria ; 
sympathetic hysteria, the disease of religious sects 
among whom enthusiasm is permitted to usurp 
the place of sobriety ; catalepsy ; catalcpsis deli- 
rans ; extasis, have been considered as specimens 
of epilepsy. The student, therefore, must acquaint 
himself with these diseases, as also with the his- 
tory of feigned epilepsy, which, not merely in the 
military hospital but in private practice, he may 
be called upon to distinguish from the genuine 
disease. Let him bear in mind that if a fit com- 
menced with a scream, if it was characterized by 
insensibility, convulsions, and foaming at the 
mouth, if it ended in sopor, and if the tongue 
were wounded or even gnawed at the edges, there 
can be but little doubt that it was epileptic. 

Prognosis. — The prognosis in epilepsy em- 
braces two heads of inquiry, viz. first, the danger 
to be apprehended firom the paroxysm ; and se- 
condly, the probability of a return. 

As epilepsy sometimes proves suddenly fatal 
during a paroxysm, our opinion must be delivered 
with a salvo in reference to such a contingencj'. 
To form a judgm.ent of the amount of danger, 
we must, first, endeavour to asceitain the species 
of epilepsy to vfhich the case belongs ; cerebral 
epilepsy being attended with more danger than 
nervous, nervous than gastric or hepatic, and these 
again than uterine : but we must not forget that 
the sympathic species of epilepsy may, by repeti- 
tion, acquire the character of the idiopathic, and 
be attended with equal danger. Secondly, we 
may oftentimes judge of the danger of the attack 
by the symptoms which precede it ; thus, in the 
cerebral species, danger may be apprehended when 
the preceding s)'mptoms indicate a fixed disease 
of the brain, as intense pain, vigilance, delirium ; 
when inroads have been made upon any cf the 
mental faculties ; and when there have been threat 
enings of paralysis. Thirdly, we are influenced 
by the violence and duration of the paroxysm. 
Those severe paroxysms which continue many 
hours often terminate in fatal exhaustion, or in an 
apoplectic state. Hence coma, after the -onvul 



84 



EPILEPSY. 



eions, is truly alarming, as it shows that apoplexy 
has actually begun. 

The probability of the return of the fits will, 
in like manner, be greatest in cerebral epilepsy, 
than in nervous, next in gastric and hepatic, and 
least in simple uterine. In cerebral epilepsy the 
fits will with most likelihood return in the cases 
in which the disease is inherited, in which the 
patient has a peculiarity in the configuration of 
his head and expression of his countenance, and 
which have been long established. Of the epi- 
lepsia stomachicaandhepatica, the cases will pro- 
bably be most obstinate which exist in connection 
with habits of self-indulgence and with weakness 
of character. Of the epilepsia nervosa the stami- 
na of the patient will in general decide our opin- 
ion both in respect of danger and repetition ; 
indeed, in every species of epilepsy recurrence 
will be more probable in a constitution defective 
in point of original vigour, or impaired by excess. 
In the epilepsia uterina we have most hopes of 
ultimate recovery, inasmuch as epilepsy will fre- 
quently cease when a change takes place in the 
function of the uterus ; as, for example, at the 
appearance or reappearance of the menses, at 
marriage or during pregnancy. 

We are inclined to think that epilepsy will be 
found more inveterate when it occurs in patients 
who are affected with chronic cutaneous affections. 
To lepra, psoriasis, ichthyosis, and porrigo, epi- 
leptics are peculiarly liable. 

Treatment. — In general, a physician now-a- 
days may unreservedly explain his views, to such 
patients as are possessed of good sense and tem- 
per, of the nature of their malady and the reme- 
dial process about to be employed, — nay, in some 
instances, may explain the doubts which are sug- 
gested by the former, and the uncertainty of the 
latter, while at the same time the solid ground on 
which he builds his hope of achieving a cure is 
clearly pointed out. But such a procedure with 
nervous patients would be highly injudicious. 
Not only are such patients, by constitution, infirm 
of purpose, but by disease are they often rendered 
additionally irresolute, and, in consequence of the 
fears which disease engenders, they are a prey to 
every pragmatical relative or acquaintance or vol- 
unteer prescriber, who may choose to insinuate 
doubts and apprehensions, suggest the necessity 
of changes, and damp and disconcert the medical 
attendant. 

When he undertakes the treatment of a case 
of epilepsy, the physician ought in the first place 
to study the patient's disposition, in nervous ill- 
nesses it being generally of as much importance 
to distinguish the shades of character as the shades 
of disease ; and, having penetrated into the inte- 
rior of his patient's mind, he must there obtain 
an ascendency not merely by knowledge of dis- 
ease, but in virtue of that influence which is gen- 
erally obtained by calmness of manner and con- 
sistency and decision of conduct. We venture to 
hazard an observation with respect to physicians 
of equal skill in the medical treatment of nervous 
diseases, that they who are not communicative 
will be more confided in and more successful than 
they who think aloud and explain all their views 
tnd plans. 

I: would lead us away from our subject, other- 



wise wc could easily show the necessity that the 
physician is under of acquiring and retainmg a 
complete control over the mind of his epileptic 
patients, and of inspiring them with hope. We 
may be permitted to state, in support of this ob- 
servation, a fact which we have often witnessed, 
namely, the temporary advantage which is gene- 
rally derived from a change of measures. When 
an epileptic patient is placed under the care of a 
confident empiric, or of a physician who is in 
great repute, the disease will often be suspended 
for a considerable time, and to the eye of a san- 
guine person appear cured ; while on the other 
hand, after a long suspension, when the disease 
returns, such disappointment is produced as to fill 
the patient with the gloom of despair, a state of 
mind which would seem to renew the energy of 
those causes upon which the fits depend, and 
hence they occur at shorter intervals and with 
greater violence than ever. 

The empiric, well knowing how much depends 
on confidence, has various methods of fixing un- 
stable minds; he cajoles and blusters, and with 
equal power of fulfilment he promises and threat- 
ens ; he knows that he may draw upon the ima- 
gination of his patient to any amount, and that 
his draft will be honoured ; that the mystery with 
which he clothes all his measures is often the 
cause of his success, and hence he provides his 
own remedies, and invests them with suppositi- 
tious activity. Give a patient a few grains of 
liquorice-powder, and let him be told that he has 
just swallowed part of the skull of a malefactor, 
(which once was considered a sovereign remedy 
for epilepsy,) or that this powder contains a sub- 
stance of which, according to the German dream- 
er, a thousandth part of a grain is the proper dose, 
and you often may thus cure a disease which is 
any thing but imaginary. In Ireland, epilepsy 
has often been cured by the priest, who is sup- 
posed by the credulous of his own communion to 
be gifted with the power of working miracles of 
healing, a power claimed for the Roman Catholic 
Church, even by her most enlightened members. 
Uneducated adherents of the Church of England, 
and even the presbyterian, both in such matters 
equally credulous, often successfully apply to the 
same functionary to be cured of fits. He some- 
times begins the curative process by giving two 
or three very powerful emetics ; but he chiefly 
relies upon obtaining dominion over his patient's 
mind, an art in which he is often eminently skill- 
ed, and which he is the better able to practise, as 
probably he implicitly believes in his own super- 
natural power. If the epileptic be a Protestant, 
the priest signifies that the prayers which he offers 
up, the virtue with which he is endowed, are his, 
only for the benefit of the members of his own 
church ; the patient, over-persuaded probably by 
his friends, goes to mass with reluctance, as a tem- 
porary expedient to qualify him for the interces- 
sion of his spiritual physician, by which means 
the latter gains an advantage over the disease. A 
struggle has taken place in the patient's mind, in 
which conscience is laid prostrate; a great and 
permanent moral impression is made, which, espe- 
cially if the disease is nervous epilepsy, sometimes 
ends in the fits being suspended, and the patient 
becoming a devoted adherent of the Church of 



EPILEPSY. 



85 



Rome, to whose interests, by his belief in the su- 
perhuman power of her clergy exercised in his 
behalf, he becomes more attached than if he had 
been born within her pale ; and confidence in the 
agency through which he has obtained relief, we 
doubt not, sometimes renders it permanent. Such 
is the nature of modern miracles, and such the 
principles by which even protestant clergymen have 
teen enabled to take a part in a farce equally dis- 
gusting to all who are able to distinguish between 
true religion and superstition. 

A successful empiric, who by various practices 
had for a long time sustained the hopes of a 
young lady who was afterwards under our care, 
one day observed her, while under a sense of 
faintness, having recourse to sal volatile ; this he 
eagerly snatched from her, and throwing up the 
sash he violently dashed the vial upon the pave- 
ment, at the same time declaring, with well-affected 
displeasure, that if he ever heard that she had any 
medicinal substance in her possession which was 
not given to her by himself, he would never see 
her again, as his remedies were so delicately com- 
bined, that, by admixture with any other drug, 
their efficacy would be completely destroyed. 

When the extrinsic occasional causes of epi- 
lepsy are removed or guarded against, the parox- 
ysm, as depending upon associations established 
within, will often return with equal violence. 
Against epilepsy thus become habitual and almost 
periodic, well sustained hope, whether rational or 
but a " fair fallacy," as were the amulets employed 
of old, will be found more efficacious than any 
other condition of the mind. Sudden alarm, 
indeed, has been called into assistance as an anti- 
epileptic remedy ; but, with Dr. Cooke, we agree 
in thinking that terror cannot be employed in the 
treatment of epilepsy, as being a remedy not suf- 
ficiently under control. From the annals of 
medicine we learn that there were other influences 
formerly much in vogue, which, acting upon the 
mind alone, must have produced permanent feel- 
ings of disgust; as for example, the following 
medicines, which may be considered as a curious 
specimen of the articles of the Materia Medica 
which, in former times, were derived from the 
animal kingdom: — Cineres talpae, muris, corvo- 
rum ; heputa ranorum ; testicula et urina apri ; 
denies humani pulverisati ; hepar hominis comes- 
tum ; sanguis hominis recens occisi ; sanguis 
patris ; secundina humana ; stercus humanum : 
There are other abominations of the same kind, 
unnecessary to specify, the use of which, Erastus 
alleges, was taught to mankind by the devil ; but 
without calling in question the active malignity 
of our great enemy, we are of opinion that man, 
when left to his own inventions, is fully equal to 
the discovery of these and a multitude of other 
therapeutic agents of equal ineptitude. 

We have known regular physicians, aware of 
the advantage which may be derived from keeping 
the imagination under the agreeable excitement of 
hope, practise upon the credulity of their patients, 
as we conceive, very unworthily. We once pos- 
sessed a prescription written by a physician of 
some name in Paris, in which the chief remedy 
prescribed by him was a polished piece of jasper 
or jade, which he ordered to be inserted under the 
skin of an epileptic patient's arm. Had he ordered 



the words of power which were supposed, by 
believers in the art magic, to be inscribed on the 
ring of Solomon, or any other talismanic charac- 
ters of equal value, to be engraved on this anti- 
epileptic fossil, his charlatanry would have been 
more perfect. The regular physician must not 
practise deception even to forward the interests of 
benevolence, but he may practise reserve, which 
will often answer better than all the mystifications 
of the empiric. Let it be matter of agreement, 
when he undertakes the treatment of a case o-f 
epilepsy, that the patient shall not know the nature 
of the medicines to be prescribed. Were we, in 
certain cases, to send our prescriptions to the apo- 
thecary sealed up, the medicines so ordered would 
produce effects which would surprise even the 
prescriber himself. 

It would be superfluous to dwellupon the import- 
ance of diet in the treatment of chronic diseases. In 
such diseases great improvement will sometimes 
arise from mere change of diet, how unobjectionable 
soever the diet may have been formerly. If, how- 
ever, a change is recommended when the indi- 
vidual first comes under our care, it behoves us to 
explain the reason of the change ; let us not, as 
some have done, change a patient's diet in such a 
manner as to abate his confidence in his former 
physician, who may have treated his case with 
judgment.* 

It is needful to stipulate that our patient shall 
no longer yield to his appetite or inclination. He 
must move by fixed rules. He must eat only 
what is placed before him by order of his physi- 
cian, not asking to have his food varied or en- 
larged. We do not exaggerate when we affirm 
that not one individual in ten, labouring under 
chronic illnesses, strictly observes the rule of diet 
which is appointed for him by his physician. 
Drunkenness, in the middle ranks of society, is 
much less prevalent than formerly. ))ut epicurism 
in eating much more so. The affected delight 
with which some popular writers have expatiated 
on the refinements and indulgences of the table 
has been, we fear, supposed real, and has given a 
stimulus to sensuality much to be deplored, espe- 
cially among young men, many of whom now put 
no restraint upon their appetite for rich and sa- 
vouiy food, while on the pleasures of the table 
they descant as shamelessly as if ihey were fit 
only for the society of Apicius. In general there 
is no difficulty in persuading patients to relinquish 
intoxicating liquors, which, as almost every sen- 



* Some practitioners living in a thoroughfare, or in 
towns ill which tlie population is constantly fluctuating, 
tliinking tliat the character of their professional hrethren 
at a distance is a matter in which they have no concern 
— thinking, moreover, that any means of advancement 
is lawful— abruptly change the measures of their prede- 
cessor in attendance, as it woulil seem, to obtain confi- 
dence It his expense. If, for example, a dyspeptic pa- 
tient i.asi been permitted to take animal food only once 
a day, Ihey will onler it to be taken at every meal 
Change of air, of occupation, a mild purgative regulany 
taken, and perhaps even, for a limited time, a full diet 
after a restricted one, will often produce a sense of great 
improvement, which it is generally thought by the pa- 
tient himself might have taken place earlier had his 
former physician been more skilful. The patient re- 
turns home full of erroneous opinions relative to diet, 
soon to experience an aggravated return of his suffer- 
ings, and fondly imagining that there is but one physi- 
cian in the land who understands his case. Iniiumerabl« 
are the phases of quackery, inasmuch as it is applicable 
to every species of credulity and mode of folly. 



86 _ 

sualist is aware, seldom fail to produce painful 
exhaustion in proportion to pleasurable excite- 
ment, and which are well known to unfit those 
who habitually indulge in their use for animal 
gratifications which are more prized; but very 
great indeed is the difficulty which we encounter 
in securing a strict acquiescence in our injunctions 
with respect to food ; and if this cannot be accom- 
plished, it would be well that the physician at once 
should decline the care of an epilectic patient. 

Having paid some attention to the proceedings 
of empirics, foreign and indigenous, regular and 
irregular, we venture to say that we may some- 
times be taught by them useful lessons ; and we 
ought not to decline assistance even from such 
sources : in this case the end will justify the 
means employed. There was some years ago, in 
Dublin, an outlandish person, said to be from Ger- 
many — a high German doctor, although by some 
it was alleged that he was a native of Ireland, and 
born in the kingdom, of Kerry — who professed to 
cure epilepsy. His appearance was such as to 
strike a vulgar mind with awe, while one who had 
pleasure in the grotesque or fantastical, or a taste 
for the antique, could scarcely help being amused 
by the public exhibition of an individual who ap- 
parently belonged to an earlier and more rude and 
credulous age of the world. With measured pace 
and serious aspect he paraded those parts of the 
city which are most frequented, displaying what 
the refined taste of our youth has rendered no 
longer a novelty — a beard like that of an adult 
goat ; behind him, almost in lock-step, there 
marched a tall fellow in a gaudy livery — light 
blue, abundantly tricked out with silver lace. Jan 
Stein, the shrewd observer of water-doctors and 
mountebanks, never painted a more characteristic 
pair than the solemn leech, whom we have slightly 
sketched, and his self-important follower. At 
first, trade was brisk with this adventurer; but he 
soon left Ireland, having discovered, to borrow an 
illustration from the agriculturist, that ground 
made to yield too rich a crop is thereby soon im- 
poverished ; and probably he also found that in no 
community is there a keener perception of the 
ludicrous or a juster estimate of character than 
among the more respectable part of the inhabitants 
of Dublin. He held some of the opinions of the 
Nazarite, for he told his patients that they must 
not cut their hair, " in which," he generally 
added, '■ lay the strength of the body," and he in- 
hibited the use of wine and all intoxicating liquors, 
a restriction not calculated to advance his reputa- 
tion in Ireland. But to have introduced this ori- 
ginal to the reader would be mere impertinence, 
were it not that there was a point in the regimen 
which he prescribed worthy of adoption. He 
ordered his patients to walk, those who were not 
enfeebled, twelve, fifteen, or even twenty miles a 
day. They were to begin by walking a moderate 
distance, and they were gradually to extend their 
walk according to their ability. In some of his 
patients a great improvement took place, both with 
respect to digestion and muscular strength, and 
this was so apparent in a short time, that ever 
since this luminary shone upon the metropolis of 
Ireland, most of our patients, afiijcted with epilepsy, 
have, by our advice, been peripatetics. We re- 
»r>jnmepd those who are subject to this disease to 



EPILEPSY. 

~^alk as far as they can without much fatigue. 
We do not prescribe one long walk, but several m 
the course of the day, of moderate length. Deli- 
cate females have thus been trained to walk eight or 
ten miles, by making them sit or recline when they 
were fiitigued, and again move on when rested. 
Females of the hysteric diathesis, who are liable 
to epilepsy, must pass as much of their time as 
possible sub dlo, driving, boating, or even sitting 
in a sheltered place, if they are unable to walk 
without being fatigued, muscular exhaustion be- 
ing generally hurtful to them. 

In prescribing a rule of diet suitable to all epi- 
leptics, moderation in quantity and simplicity in 
the preparation of food are indispensable points. 
If the diet of an epileptic has been either too high 
or too low, it ought to be changed. We conceive 
the diet which would best preserve an individual 
liable to scrofula from an attack of that disease, 
would be best suited to a patient liable to epilepsy. 
Fermented liquors, however, should be in general 
altogether withheld. Flesh meat ought to form 
the principal part of one if not two meals in the 
day ; and milk, if it agrees, that is, if it does not 
retard digestion, which it is less Uable to do when 
fermented liquors are laid aside, is the article next 
in value. The epileptic ought to be trained so as 
to be in good wind, or, in other words, his mus- 
cles ought to be in a state of the utmost strength 
and firmness. If we permit ourselves to take a 
lesson from empirics, we may surely avail our- 
selves of such information as may be derived from 
a brotherhood at least as respectable, namely, the 
gentlemen of the fancy, as they are called, or we 
may have epileptics trained as were the athletae in 
ancient times. 

When the patient leaves his bed in the morn- 
ing, he may have a rusk or a slice of toasted 
bread with an egg beat up in a teacupful of warm 
milk and water; then let him dress, make all 
needful arrangements, and walk three or four 
miles. Two hours or more after he has left his 
bed, let him have his second meal, — milk, or cream 
in water, or cocoa, with bread a day old and good 
butter. It may be observed that wheatcn flour is 
very generally adulterated with bean and potato 
flour, both of which injure the quality of bread, 
and that butter is much oftener rancid than good. 
Let the patient rest for three hours after breakfast, 
and this will be the best time to devote to business 
or education. Then he must again walk, if an 
adult possessed of sufficient vigour, from five to 
eight miles. At from five to six hours after his 
second meal let him have a third, consisting of 
meat of the best quality, — mutton excluding fat, 
poultry, game, or very tender beef, roasted or 
boiled, of which an adult must not eat more than 
six ounces ; bread, and one moderate helping of 
tender well-boiled vegetables ; of drink — not more 
than p common tumblerful must be taken, distilled 
water. Seltzer water with a little milk, or toast and 
water, being equally proper. Then the individual 
may rest for two hours, but we would not have 
him lie after meals as some have recommended, 
this having appeared to us to retard rather than 
to promote digestion, probably by disturbing the 
circulation: he may stroll in "a garden, read an 
amusing book, or chat with an agreeable friend, 
only such occupation being permitted as will not 



EPILEPSY. 



87 



raise the pulse by one beat ; he may then resume 
more active exercise for an hour or two. In five 
or six hours after dinner a Ught supper may be 
taken, consisting of not more than four ounces of 
meat with bread, or a cup of milk with a water- 
biscuit The rest of the evening may be spent in 
cheerful society, in a large airy room, not over- 
liglited nor overheated, but sufficiently warm to 
prevent that chill which in the latter part of the 
day often follows very active exercise ; and every 
occupation by which the mind is depressed, or is 
excited and thereby subsequently exhausted, must 
be avoided. The patient must be in bed at eleven 
and up at six, nothing in general being more 
hurtful to epileptics than sleep unnecessarily pro- 
longed. 

The scalp in all epileptics ought to be shaved 
once a week, (a few ringlets at the temples and 
in front being permitted to grow,) and daily well 
rubbed with a flesh-brush after the tepid shower- 
bath, or what answers nearly as well and gives 
less trouble, after pouring a flagon of tepid water 
on the head inclined over a large basin. The hat 
or cap worn must be of the lightest kind, a straw 
hat, or a light foraging-cap of cloth, which may 
be replaced, when within doors, by a nightcap of 
woven silk worn single. The patient may gra- 
dually bring himself to sleep without a nightcap, 
and without curtains, both of which lead to effe- 
minacy ; with his shoulders and head raised and 
his feet well protected from the cold, in a chamber 
as large and airy as possible, and without a fire ; 
there may, however, in winter, be a fire in his 
dressing-room, or his bed may be warmed. The 
temperature of his extremities must always be 
supported by means of exercise, friction, or proper 
clothing. 

A patient liable to epilepsy must not be per- 
mitted to ride, or to hold the reins in a carriage. 
The grates in all the apartments which he fre- 
quents ought to be guarded by a deep and strong 
fender ; he ought to avoid the streets of a crowded 
city, in which the whirl of carriages, the tide of 
human beings, the stunning confusion of sounds, 
and the multiplicity and distraction of objects, 
produce a vertiginous hurry of thought, which to 
him is ever dangerous. He ought not to walk 
near water. One of our earliest patients, a fine 
young man of twenty, came to an untimely end 
in his own garden, by falling into a runnel, in 
which he was drowned, although the water was 
not more than four inches deep. Lastly, if his 
circumstances admit of his having an attendant, 
the epileptic ought never to be alone. His compa- 
nion ought to be provided with a nervous draught, 
consisting of camphor mixture and ether or am- 
monia, by taking which there is reason to think 
that the paroxysm may be averted in the gastric 
OT nervous species of epilepsy ; with a wedge of 
soft wood to interpose between the teeth ; with a 
piece of broad tape to be applied to the superior 
part of the limb, if the paroxysm should commence 
with the aura in the extremities ; and with an air- 
pillow to inflate, and place under the patient's 
head, when he is attacked in the open air. If the 
attack takes place in his chamber, the patient 
ought to be laid on his back on a French bed, 
with at least one attendant standing on either 
side to prevent him from injury during the struggle. 



If he is much flushed, his head and shoulders ought 
to be elevated, the warmth of his extremities sup- 
ported, while at the same time air is freely ad- 
mitted into the room. All attempts to make hihi 
swallow, or to stimiJS..-3 the nostrils, are improper. 
A medical practitioner ought to be sent for and 
ought to remain in attendance while the slruggk^ 
lasts. In a first attack, if the fit is severe, blood 
ought to be procured from the temporal artery, a 
precaution which will also be necessary in patients 
of an apoplectic diathesis, whensoever they labour 
under a prolonged fit of epilepsy. 

[Compression of the carotids has likewise been 
found serviceable, not only in the way of preven 
tion, but during the paroxysm.] 

Most of the foregoing observations apply to 
every case of epilepsy. Having endeavoured to 
determine the variety to which the case belongs, 
a point in general overlooked by the nostrum 
mongers, we have now to point out the specifii 
treatment which will be required. We are in the 
first place to ascertain whether there exist any 
symptoms of present danger ; and, secondly, to 
apply ourselves "to the more continued treatment 
required in the disease considered as a chronic af- 
fection." (Prichard.) 

Epilepsia cerebralis. — If the case belong to 
cerebral epilepsy, we must endeavour to discover 
the condition of the vessels with respect to in- 
creased action or congestion ; if in a state of ex- 
citement or turgescence, they must be relieved 
without delay, by means of general or local bleed- 
ing, or by antimonials, with mercurial purgatives, 
and the antiphlogistic regimen. At every pa- 
roxysm, as soon as the patient awakes from that 
sleep which is part of the crisis, he ought to be 
examined with care by a medical practitioner. 
We conceive, were this uniformly done, and the 
necessary treatment immediately adopted, that in 
many instances the subsequent attack would be 
milder and more distant, the faculties of the mind 
would be less endangered, and the probability of 
ultimate recovery would be greater. Many chronic 
affections are merely a series of imperfect reco- 
veries from attacks of acute diseases. This we 
have seen exemplified on a large scale in the 
House of Industry in Dublin, which in formei 
times was filled with paupers, the victims of pover- 
ty and intemperance, mostly labouring under 
chronic disorders of the viscera. Many of these 
outcasts from society passed much of their time 
in the subsidiary hospitals, to which they were 
sent when they were affected with febrile attacks, 
of which a considerable portion of them died ; 
each recurrence of fever assuming a darker com- 
plexion in consequence of recovery from its pre- 
cursor being incomplete. In epilepsy, if due at- 
tention were paid after every return of the convul- 
sions to establish the fact of perfect recovery, we 
are persuaded that the patient might often preserve 
his place in society, instead of becoming from 
chronic disease of the brain, originating in or ag- 
gravated by the severe paroxysms, a mere driveller, 
as is the lot of many an epileptic in the latter 
part of his life. And this view is strengthened 
by the fact that some patients are reduced to idiot- 
ism, not so much by the natural course of diseaw 
as by vicious habits in which they indulge, which 
not only confirm the predisposition to "pilepsy 



EPILEPSY. 



I'Ut injure the brain and nervous system : " L'abus 
lies liqueurs alcohoiiques, les execs veneriens, ct 
la masturbation aggravent I'epilepsie et precipitent 
la porte de la raison." (Georget, 1. c.) 

The paroxysms of epilepsia cerebralis chiefly 
occur, to use an expression of Fothergill's, " in 
the plenitude of health ;" and when this is the 
case, we ma}' pursue the plan about to be recom- 
mended with more confidence. 

In treating this form of epilepsy we apply the 
principle of revulsion, explaining that term, not as 
the driving back of the fluids from one part to 
determine them to another, but simply as expres- 
sive of the relief to be obtained for an organ in 
which a morbid process is going forward, by in- 
ducing a more vigorous state of the circulation in 
other organs, or by the establishment of a process 
of counter-action in a remote sympatliizing part. 
With this view we have to recommend, first, once 
a month the cupping-glasses and scarificator to be 
applied to the nucha, and a few ounces of blood 
to be by that means taken away ; secondly, dry- 
cupping to be practised between or over the scapula 
every third or fourth day, two cupping-glasses to 
be allowed to adhere for a quarter of an hour; 
thirdly, a caustic issue (which is less troublesome 
and painful in dressing than a seton) to be made 
in the back of the neck where the seton is usually 
inserted ; and, lastly, once in the week, a moxa, 
or a blister, not larger than a crown-piece, to be 
ai)plied to the back of the head, behind the upper 
part of the ear, where there is space for a succes- 
sion of four such blisters. If a blister be preferred 
to a moxa, let it be put on at noon, and it will be 
ready to be dressed before bed-time, by which 
means the patient's rest will not be broken, as it 
generally is, by a blister, however small, applied 
at bed-time. There is abundant evidence of epi- 
lepsy being moderated while a discharge has been 
maintained, from a sore either accidentally occur- 
ring or designedly produced, and being aggravated 
almost immediately after such discharge has been 
dried up. 

In epilepsia cerebralis we wish to promote a 
inore active circulation in the muscular tissue, and 
in the integuments, especially of the limbs, which 
is to be done by champooing and frictions, while 
the head is kept cool and the shower-bath taken 
daily. Our hope of cure in this form of epilepsy 
chiefly rests on persevering attention being paid 
to diet and regimen, and on topical means ; yet 
although our confidence in the use of internal 
medicines is not so great in this as in the other 
species of the disease, they are not to be dis- 
pensed with, when the functions of the cuta- 
neous, gastro- hepatic, or nervous systems are dis- 
ojdered 

Antimonials are requisite when the skin is in- 
ictive, and we have known signal benefit afforded 
by antimony to those persons who, in advanced 
life, have laboured under the apoplectic epilepsy, 
as it has been called. The preparation of anti- 
moiy which we prefer is James's powder, the 
pulvis Jacobi veri, and the following is the method 
o( exhibiting it which we recommtnded a good 
inany years ago, and which has often been adopted 
since with advantage. (Dublin Hospital Reports, 
vol. I. p. 315.) The patient is to begin with a 
v-iry 'noderate dose of the powder, not more than 



two or three grains at bed-time, and to increase 
the dose by half a grain every night, till some 
sensible effect is produced on the skin, stomach, 
or bowels. Should the stomach at any time be 
affected with sickness, the dose may be lessened 
by a grain on the following night. By the addi- 
tion of a few grains of rhubarb, a larger quantity 
of James's powder may be administered than the 
stomach could otherwise bear. If the skin be 
affected, the dose should not further be increased, 
but it must be repeated every night for about three 
weeks ; it may then be reduced as it was aug- 
mented by half a grain every night, the course 
occupying a period of at least six weeks. We 
have known eighteen or twenty grains taken every 
night for a considerable time without inconve- 
nience, and even when not productive of any sen- 
sible perspiration, it has often allayed the heat and 
restlessness which so often accompany irregular 
determinations of blood. In very cold weather 
we have directed the patient to make some addi- 
tion in point of clothing, but have not confined 
him to the house even when the snow was on the 
ground ; as we do not consider the system to be 
more susceptible of catarrhal or rheumatic affec- 
tions while under the influence of James's pow- 
der. To this course of medicine the tepid bath 
will prove a valuable addition. 

If there be any of those scaly affections of the 
skin to which epileptics are so liable, a draught as 
follows may be taken : 

R Radicis sarsaparillse concisje, ^i. 

Radicis glycyrrhizae concisae, ^ii. 

Aquse calcis, uncias x. 
Macera in vase clauso, subinde agitans, per horas 
duodecim, dein cola. Divide in haustus sex. 
Sumat unum ter quotidie. 

When the eruption is not attended with inflam- 
matory heat or itching, the aqua picis liquids may 
be given to the extent of from half a pint to a 
pint in the day, or as a substitute the piluliB pices. 
In indigestion with a loaded tongue, the nitro- 
muriatic acid may be deserving of a trial, two or 
three minims of the nitric acid, with four or five 
of the muriatic, in three ounces of distilled water, 
may be sucked up through a glass tube or a reed, 
at least three times a day. Where the breath is 
heavy, the following powder may be given. 
R Pulveris recentis carbonis ligni, gr. xv. 

Pulveris rhei, gr. ii. 

Pulveris ipecacuanhae, gr. i. M. 

F. Pulvis e cyatho vin. aquae cinnam. bis quoti- 
die sumendus. 

If the urine be scanty, with a red sediment, a 
drachm of Brandish's alkaline solution in water, 
or an a'kabne biUer draught, may be taken every 
forenoon and evening. We do not object to the 
occasional use of mercury, but we have never, in 
this form of epilepsy, willingly given that mineral 
so as to affect the mouth. If the bowels are con- 
be"d tim'e" '' '''"''"^"^ ^^"^ ^^^ ^e given at 
K Extracti aloes, 

G. galbani, sing. gr. ii. 
oaponis duri, gr. i. ]Vf. 
Or the following powder, which wa< tli^ r 



jSPILEPSY. 



R Sulphuris loti, 9'- 

Sulphatis potassse, ^r, x. 

Pulveris rhei, gr. v 

Pulv. nucis moschitJE, gr. :i, M. 
Lastly, if the nervous systeip be irritable, the 
patient desponding and apprehensive, the treat- 
ment to be recommended under the head of Lpi- 
lepsia Nervosa will probably afford relief. 

Epilepsia S/omachica. — We once had a patient 
who, in the early part of his life, had been under 
the care of the celebrated Dr. Cullen. Dr. CuUen 
kept him in a state of unceasing nausea for a very 
long time, — our impression is, for more than a 
year, — and without the slightest relief. It is not 
so that we would have emetics employed. We 
conceive that attacks of epilepsy may sometimes 
be parried by giving emetics at stated periods, and 
we have been accustomed to prescribe the follow- 
ing emetic in this form of epilepsy, once in the 
week : 

R Pulv. ipecacuanhee, gr. xv, 

Sulph. zinci, gr. v. M. 
Two cases of the epilepsia stomachica were 
successfully treated by giving, once a week, a calo- 
mel bolus at bed-time, and on the following morn- 
ing a draught containing castor-oil and oil of tur- 
pentine in the following doses : 
H Olei ricini, J^iii. 

Olei terebinthinse, ^ii. 

Mucilaginis acaciae ^iii- 

Aquae menthse viridis, ^vi. M. 
To the best of our recollection, both patients 
had a pill of aloes and soap every second day, 
took bitter medicines, and had their diet regulated 
with great care, more especially with regard to 
quantity. 

In this form of epilepsy, the bowels ought to 
be completely emptied, every second day, by 
means of a dinner-pill, and the use of the injec- 
tion syringe.* The dinner-pill may consist of 
two, three, or four grains of the pilulffi aloes com- 
positae, or the pilulae aloes cum myrrha, or of the 
piluljE stomachicae Mesues, now by an altered 
name, contributing to the medical fame of Lady 
Webster, and which owes its etiicacy solely to the 
aloes which it contains, and to its diffusion among 
a mass of solid aliment. A pilula ante cibum 
ought not to contain more than a grain and a half 
or two grains of aloes, or to be taken every day. 
The injection may consist of a pint or more of 
tepid or cold water, with or without two or three 
drachms of the muriate of soda. 

Once every week the bowels ought to be fully 
evacuated by giving at bed-time a medicine act- 



* When the bowels refuse to acl regularly without the 
assistance of medicine, wliich is the case with many 
persons advancing in life, it is an error to order a purjia- 
tive every day ; the evacuation procured by medicine is 
generally so complete that a longer time elapses before 
the bowels fill than after a natural stool, therefore the 
purgatives rt!sorted to, whether aloetic pill in tlie even- 
ing, or a saline aperient before breakfast, ought to be 
taken only on each alternate day. Their contents ought 
to be permitted sufficiently t^ accumulate before the 
bowels are again urged to discharge themselves of their 
load ; by this means the cathartic being more completely 
incorporated with the ficcal residuum, irritation and 
mucous stools will be avoided. If a purgative be taken 
wh('n the bowels are comparatively empty, more fre- 
quent discharges will be obtained, but they will be less 
consistent and satisfactory ; and griping and tenesmus, 
and perhaps hec lorrhoidal irritation, will be the conse- 
quence. 

Vol. Tl 2 h* 



ing upon the iiver, stomach, and small and great 
intestines : 

R Hydrarg. submuriatis, gr. ii. 
Pulv. ipecacuanhas, gr. i. 
Pulv. rhei. gr. iv. 
Extr. aloes, gr. ii. M. 
F. pilulae ii. hora somni sumendae; 
and the following morning before breakfast, a sa- 
line aperient draught. 

At the same time the patient must have a tonic 
medicine, twice in the day, containing half an 
ounce or six drachms of the atramcntum Heber- 
denii, now introduced into the Dublin Pharmaco- 
poeia under the designatiorl of mistura ferri aro- 
matica, or an ounce of the mistura ferri composita, 
or the following draught : 

R Sulph. ferri, gr. iii. 
Sulph. quinins, gr. i. 
Infusi calumbae, ^i. 
Ac. sulph. dil. m. iii. M. 

It is in this species of epilepsy and in nervous 
epilepsy, that benefit may occasionally be obtained 
from the nitras argenti and cuprum ammoniatum. 
In the cerebral species we have repeatedly tried 
the former medicine, in the dose of nine or ten 
grains a day, for a sufficient length of time, with- 
out the slightest benefit. 

Among the means most likely to improve the 
state of the digestive system, there is not any 
which is so uniformly beneficial as change of resi- 
dence and travelling, and the improvement is often 
felt for many weeks after a movement. Journeys, 
in the case of the epileptic, who naturally dis- 
likes to expose his infirmity to strangers, ought to 
be undertaken shortly after an attack, as a con- 
siderable period of time generally elapses before 
the fit may be expected to return. It would ap- 
pear from the following observation, made by De 
Haen, that changes of residence and long jour- 
neys have sometimes cured the disease. " Etiam 
mutatione domicilii, diuturniore peregrinatione, 
vitoe genere prorsum permutato, quidam legun- 
tur se etiam ab ipsa gentilitia labe praestitisse im- 
munes." 

Epilepsy has sometimes arisen from taenia. 
When this takes place the treatment will not be 
attended with much difficulty, as the disease may 
be removed either by means of rectified oil of tur- 
pentine, or by tin in powder given in large doses, 
and followed by cathartics. We have found in 
some individuals, that after worms, especially as- 
carides, have been expelled, so that there was no 
vestige of them for several weeks, they have re- 
appeared within two months, as if a nidus had 
been left behind. In such patients, worms may 
be permanently destroyed by exhibiting proper 
anthelmintics before the expected period of recur- 
rence, which may easily be ascertained. 

Epilepsia hepatica. — When hepatalgia, bihary 
colic, icterus, or any other symptom of biliary 
congestion, precedes or follows an attack of epi 
lepsy, local bleeding, an issue over the region of 
the liver, and mercurial purgatives will be requi- 
site, and afterwards alternate courses of dilut« 
nitro-muriatic acid and of taraxacum, the lattei 
exhibited as follows : 

R Extracti taraxaci, ^ii. 
Extracti gentianae, gr. x. 
Olei cini lam. min. ii. M. et divide in 



90 



EPILEPSY. 



pilulas xii ajquales. Sumat tres ter quotidie su- 
perbib. haustum decocti taraxaci 
R Taraxaci, ^ii. 

Extr. glycyrrhizae, gii. 

A quae ferventis quod satis sit ut colen- 
lur uncijc decern. Coque per hone tertiam par- 
tem et cola. Colaturffi adde supertartratis potassae, 
giss. Divide in haustus sex. 

Epilepsia nervosa. — The chief indication in 
this species of epilepsy, after the removal of the 
exciting cause, is to allay the irritability of the 
stomach and to strengthen the system. The sto- 
mach is ever disturbed, the disturbance evincing 
itself not in anorexia but in despondency, in irri- 
tability of mind, in the animus, nee sponte, vari 
us et mutabilis, in depression of strength, unre- 
freshing sleep, and often in that most distressing 
sensation which has been called " the fidgets ;" 
in palpitation, in acute pain in the mamma, and 
in the existence of various other symptoms of 
hysteria. In neither males nor females, is this 
variety of epilepsy connected with the state of the 
generative system, unless when the attacks pro- 
ceed ex onanismo. 

In nervous epilepsy our chief reliance is upon 
diet, regimen, attention to the state of the bowels, 
proper regulation of the mind ; and on such medi- 
cines as valerian, camphor, snake-root, and castor. 
The following draught we have often known to re- 
lieve the irritable state of the nerves which attends 
this species of epilepsy. 

R Radicis valerianse, 

Radicis serpentarifB, aa. ^ii. 

Aquse ferventis, §vii. digere per horam, 
et liquorem frigefactum cola. Colaturae adde 

Sp. ammoniae aromatici, ^ii. 

Tincturae serpentariae, ^vi. M. et di- 
vide in haustus sex. Sumat unum meridie et 
vesperi. 

Tonics are also applicable to this affection, as 
cinchona and iron, especially the former when 
epilepsy is periodic. We have known moderate 
doses of nitrate of silver given with advantage in 
aggravated hysteria, and hence, although we have 
not successfully prescribed it in nervous epilepsy, 
unless in one instance, there are many cases of 
this variety of the disease in which it would pro- 
bably be of great use. Much may be expected 
from agreeable occupation, variety of scenery, the 
bracing air of the sea, and tepid and cold sea- 
bathing. All kinds of fermented liquor, tea, and 
also coffee, ought to be given up, together with 
the use of tobacco, if unhappily the patient should 
have addicted himself to the use of that poisonous 
and demoralizing weed.* 

* Tobacco is an eiioiny to domestic economy and per- 
sonal cleanliness; it taints tlie brea'h permanently, in. 
jiires the digestion, impairs the intellect, and it oven 
shortens the life of some of its votaries. Cullen says it 
produces loss of memory before the usual period. Snuff 
keeps a great many of the females, engaged in lace-mak- 
ing, in this neighbourhood (Newport Pagnell), under the 
continued influence of hysteria, and gives them an early 
stamp of age; at thirty a snuff-taker looks as if she were 
forty years old. It is the sole cause of a variety of dys- 
pepsia, of which we have witnessed a vast number of 
instances— the symptoms being a painful sensation of a 
lump at the stomach — of a hard undigested substance 
pressing, as it were, upon a tender part of the stomach, 
w hich sensation is, for the time, relieved by taking food ; 
remarkable depression of spirits, every thing seen 
through a medium of gloom and distrust; and tremors 
»f the nerves. " Upon an accidental interruption of 
Kiuff-taking for a few days, the pains do not occur, upon 



Epilepsia uterlna.—\i the attacks of epilepsy 
precede the menstrual period or accompany it, the 
effort of the constitution being imperfect, relief 
must be sought for in venesection, purgatives, and 
the antiphlogistic regimen. In the interval be- 
tween the periods, those enimenagogues must be 
employed which moderately act upon the intes- 
tines, and at the same time give vigour to the cir- 
culation ; as, for example, pills of myrrh, sulphate 
of iron, and aloes ; or pretty full doses, two or 
three times in the day, of the carbonate of iron, 
with a moderate dose, every second night, of the 
decoctum aloes compositum. The tepid pedilu- 
vium, or hip-bath, with friction of the back and 
limbs at bed-time, more especially just b(>fore the 
menstrual period, may be practised ; and in this 
species of epilepsy also the patient ought to have 
the benefit of sea-bathing, and frequent changes 
of residence. 

There is a point from which our attention 
ought never to be withdrawn in the treatment of 
epilepsy, namely, the exciting cause of the first 
paroxysm. If the paroxy.sm have been caused by 
mental impre.ssions, not only ought the causes of 
fear, anxiety, and displeasure, to be as much as 
possible removed, but endeavours ought to be 
used to strengthen the mind. If from excess of 
any kind, then every method of renovation must 
be employed. If from inanition, proper restora- 
tives must statedly be exhibited. If the disease be 
periodic and connected with dysmenorrhcca, after 
evacuations, if they are indicated, anodynes, even 
in large doses, will be necessary ; of which the fol- 
lowing will be found one of the most efficacious : — 
R C amphorae, (ope sp. vini rect. in 
pulv. red) ^ss. 
Extracti hyoscyami, gr. xv. 
Extracti opii, gr. iii. M. et divide in pil. 
xii aequales. 

Of these compound camphor pills two may be 
taken on the very first accession of pain, two in 
an hour after, and even a third dose may be taken 
after a second hour ; if relief is not obtained, some- 
times a double or even quadruple portion of opium 
must be given ; it being an established point of 
practice that the pain which attends dysmenor- 
rhoca is to be subdued without loss of time. We 
apprehend that the efficacy of full doses of cam- 
phor on painful menstruation is not so generally 
known as is desirable. 

To propose a regimen of diet which would ap- 
ply to every variety of epilepsy, as we have already 
hinted, would lead to a disproportionate extension 
of this article. The directions, therefore, which 
we have given, are of necessity general, and may 
be departed from should the paroxysms return 
with unabated frequency. Eminent physicians, 
as for example Ih: Fothergill, have recommended 
abstinence from all kinds of animal food and fer 
mented liquors. He tells us that, " In the form 
of epilepsy, which may be supposed to proceed 
from disorder of the digestive organs, evidenced in 
craving appetite, and supported by inattention to 

vol. II. p. 2,5.) Che^ving tobacco will produce the same 
rf. rZV pfr."'"^ """"•"^''^ anorexiu\-,nd en.aciation. 
Thpchief evil, however, in tobacoo, taken in anv way, 
IS that It leads myriads upon myriads ," le hal.rtual 
use of ardent spirits and opium, and consenueiil v to 
the ruin of soul, body, and estate. constqueuliy 



EPILEPSY — EPISTAXIS 



91 



diet, laxatives, with a light chalybeate interposed 
and steadily continued, together with a course of 
diet consisting of milk, vegetables, fruits, and 
things prepared from them, and in moderate quan- 
tities, seldom fail of removing the disorder." 

In Heberdcri's Commentaries we have the fol- 
lowing pithy illustration of the importance of diet : 
" Duo epileptici ab omni cibo animali abstinue- 
runt, et sanati sunt." And Dr. Abercrombie, no 
mean authority in this or in any practical point, 
is of opinion that the only remedies of real efficacy 
in such cases are purgatives, a strictly vegetable 
diet, and total abstinence from strong liquors. 
According to our experience it would not be easy 
to overrate the importance of diet in epilepsy, at 
the same time we admit that many changes may 
be necessary before the full advantage is obtained 
which diet is capable of yielding ; one rule alone, 
in our opinion, being established, namely, that 
food ought ever to be taken in great moderation ^ 
in other words, that there is danger in a full meal, 
however unexceptionable the materials may be of 
which it consists. 

When, in medical works of respectability, we 
meet with a variety of remedies, many of them 
possessed of dissimilar qualities, recommended for 
the cure of the same disease, we must conclude 
that its species are dissimilar in their nature, and 
require to be treated differently. In examining 
the anti-epileptic remedies recommended by au- 
thors, we may discover four classes, viz. evacuants, 
tonics, nervines, and emmenagogues: first, those 
which reduce vascular congestion or action, venee- 
sectio, hirudines, fonticuli, setacca, cauterium, ve- 
sicatoria, irritantia, emetica, purgantia, antimoni- 
um, mercurius : secondly, those which invigorate 
the body and improve the digestion — aeris et 
dietae mutatio, balneum frigidum, cinchona, amara, 
acida, zincum, argenti nilras, cuprum [artemisia 
vulgaris] : thirdly, medicines which relieve disor- 
ders of the nerves — serpentaria, cardamomum, 
Valeriana, castoreum, moschus, campbora, guaia- 
cum, hyoscyamus, belladonna, stramonium, opi- 
um : fourthly, emmenagogues — ammonia, galba- 
num, assafoetida, aloes, ferrum, oleum tercbinthinse, 
ruta. A consideration of the foregoing catalogue 
would justify the division of the subject which in 
tliis article has been adopted. 

[Of late j-ears, indigo given in very large doses, 
has been extolled by many practitioners. The 
writer witnessed numerous trials with it in the 
Philadelphia Hospital ; but its efficacy was not 
marked. (See his New Remedies, 4th edit. p. 
363, Philad. 1843.) Where epilepsy has been 
caused by an external injury of the head, the ope- 
ration of trephining has been practised ; and in 
some cases the results have been happy. The 
operation is, however, of a serious character, and 
ought I ot to be had recourse to, unless there is 
every ^yiospect that the cause of the disease is 
seated in parts which can be removed by the tre- 
phine.] 

If the necessity of more diligently studying epi- 
lepsy, of more carefully attending to its specific 
difl'erences ; if the inapplicability to some cases of 
epilepsy of the treatment which has succeeded in 
others, be admitted and acted upon, happier prac- 
tical results will probably be the consequence. 
But, lest the reader should suppose that wr are j 



too sanguine in this our expectation, he shall have 
the concurrent testimony of the venerable com- 
mentator on Boerhaave produced, to whose au- 
thority he will more readily yield : " Illis observa- 
tionibus sic collectis et in ordinem digestis, sedulo 
expendat medicus omnia, et facile deteget regulas 
agendorum et vitandorum, sed in singulari tantum 
hujus {Egri casu. Nam generales in omnibus epi- 
lepticis curandis regulae haberi nequeunt ; quod 
enim uni prodest, saepe nocet alteri. Ubi hoc 
factum, tota difficultas evanuit, nam reliquum est 
tantum facilis executio bene perpensarum rerum. 
Certum est, medicos, luculenta praxi obrutos, 
saspe deficere in cura hujus moibi, cum tempus 
ipsis non sufficiat, ut singulari ocgro tantam curam 
impendant; verum et doluerunt toties, a;groruni 
custodes observasse ilia, quae ipsi neglexerant, non 
sine famae damno. Credo firmissime, si omnem 
animi attentionem adhiberent his medici, quod 
sanarent plures epilepticos, et levamen adferei.c 

fere omnibus." — Sect. lOSO. t /-^ 

J. Cheyne. 

EPISTAXIS, (derived from h\ and ardln. 
stillatio, from (rra'^o), siilo,') a flow of blood from 
the nose. This is one of the subdivisions of the 
natural class of disorders termed hemorrhages, to 
which article in this work (in order to avoid un- 
necessary repetition) we refer for a general expla- 
nation of the circumstances under which it takes 
place. 

Bleeding from the nose is a physical phenome- 
non too common and conspicuous to have escaped 
notice at any period ; and from the earliest times 
its consequences, together with the conditions of 
the body which have accompanied and preceded 
it, have been objects of medical observation. The 
word epistaxis has, also, from a very early period, 
been applied to this affection under whatever cir- 
cumstances existing ; but it is evident that Hip- 
pocrates, who has left us several observations on 
the subject, used its original always to signify an 
oozing, and a'lfioppayia, a rush of blood : we make, 
however, no such distinctions. 

Of the various hemorrhages, epistaxis is the 
most common ; and so often is it attended with 
salutary effects, that its encouragement and sup- 
pression equally require the consideration of the 
medical practitioner. Its frequency is readily ac- 
counted for when we reflect on the structure of 
the Schneiderian membrane ; its extreme tenuity, 
and the number as well as proportionate size of the 
ramifications of blood-vessels which traverse it in 
every direction, forming a complete net-work, with 
a comparatively smaller portion of interstitial cel- 
lular substance and thinner lamina of membrane 
enveloping it than is to be found in any other part 
of the body. The blood-vessels of this membrane 
being for the most part supplied by the internal 
maxillary artery, and inosculating with some of 
the extreme ramifications of the internal carotid, 
any increased impetus given to the latter, or to 
the trunk of the former, is less resisted in this 
part ; and, in consequence of the rupture which i» 
very frequently occasioned, an escape of blood is 
eflfected, with relief of both these systems of ves- 
sels, and, in a very essential manner, to the ad- 
vantage of the brain. 

As in hemorrhages from every other part, it is 
important to observe that in epistaxis there ar- 



92 



EPISTAXIS. 



two opposite conditions of the blood-vessels, in- 
duced by corresponding states of the body under 
which it occurs : in the one the extreme vessels 
are ruptured by the increased activity of the cir- 
culatory system, general and local ; in the other, 
from debility and relaxation their elasticity is de- 
stroyed, and, incapable of distension as well as of 
propelling their contents, their parietes readily 
give way ; or, from the same condition, red blood 
insinuates itself through the exha'ents, instead of 
the thinner and colourless part of this fluid proper 
to them. We shall proceed to consider epistaxis 
under these two conditions, adopting the common 
language of pathologists in applying to the former 
the term active or entonic, and to the latter pas- 
sive or atonic epistaxis. [Like other hemorrha- 
ges, epistaxis may arise from mechanical hyperae- 
mia — in other words, from some physical obstacle 
to the return of the blood from the mucous mem- 
brane to the heart.] 

Entonic epistaxis occurs occasionally in very 
young children, most frequently before or about 
the age of puberty, and in persons of a plethoric 
or sanguine temperament ; the latter are not un- 
frequently the objects of it until the advances of 
age effect a change on the constitution, and the 
balance of power is transferred from the arterial 
to the venous system. Thus we find in early 
life that this hemorrhage is almost always from 
the arteries, and in old persons, when it does 
occur, that the blood flows from the venous sys- 
tem. The habits and exercises of males render 
them more liable to epistaxis than females ; but 
on the other hand we find in the latter that it is 
very often vicarious with the suppression of the 
menstrual discharge, and occasionally occurs with 
the same periodical exactness. Even in the male 
sex the influence of habit is often evinced in the 
occurrence of epistaxis, and, after other causes 
have been removed, it is sometimes with difficulty 
that its power is resisted. 

Local injury, inordinate exercise, exposure to 
heat, or increased temperature of the atmosphere ; 
hot drinks, stimulating diet, suppressed discharges, 
either natural or artificial; and all other circum- 
stances which increase the quantity of blood, or 
the impetus by which it is distributed to the dif- 
ferent parts of the head, may occasion the occur- 
rence of epistaxis. 

In addition to these causes, it has been fre- 
quently preceded by various emotions of mind, 
terror, anger, and even a single excitement of the 
imagination ; hence, says Mason Good, we may 
•eadily trace by what means the philosophers and 
poets of the eastern world, and even some of those 
of the western, were led to regard the nose as the 
seat of mental irritation, the peculiar organ of 
heat, wrath, and anger; and discover how the 
same term t]X {ap or aph) came to be employed 
among the Hebrews to signify both the organ and 
Its effect, the nose, and the passion of anger to 
which it was supposed to give rise. 

In some mdividuals it is probable that there is 
an extraordinary delicacy of the Schneiderian 
membrane and its vessels, which renders the latter 
peculiarly easy of laceration : there appears also to 
be a degree of correspondence between this ex- 
pansion and the integuments of the face with 
which it is continuous, the phenomenon of blush- 



ing being oftei remarkable in persons subject to 
epistaxis, a cii cumstance which is doubtless also 
in great part U be referred to the identity of tem- 
perament predisposing to both of these affections. 
Excitation of the olfactory nerves, in persons 
of peculiar irritability of the organ of smell, has 
occasionally induced epistaxis ; an example of 
this kind has been recorded by Bruyerin, in which 
it was induced by smelling an apple : and another 
by Rhodius, in which the odour of a rose appeared 
to be the exciting cause. Coughing, sneezing, 
singing, and reading aloud for any length of time, 
stooping also, and particular postures of the body, 
have not unfrequently occasioned it. The secre- 
tory office of the Schneiderian membrane is liable 
to material interruptions from the vicissitudes of 
temperature to which it is necessarily exposed in 
the act of respiration ; and any check by cold to 
its natural or inordinate secretion will occasionally 
lead to the rupture of blood-vessels in this part. 

The febrile disorders which are attended with 
determination of blood to the head are often the 
precursors of epistaxis ; and this affection, from 
the days of Hippocrates, who pronounced it criti. 
cal, an expression which has been adopted through 
succeeding ages to the present day, has been wel- 
comed as a salutary effort of nature, either to 
reheve or bring the disorder to a favourable issue. 
Some nice distinctions have been drawn, by the 
great authority just mentioned, of the different in- 
dications from the occurrence of epistaxis on 
different days of the progress of fever ; but inde- 
pendently of their being inapplicable to the fevers 
of this country, more extended experience has 
shown that this is to be regarded as only one of 
an assemblage of symptoms from which our judg- 
ment of the issue of such diseases can reasonably 
be drawn. 

Epistaxis has sometimes been observed to be 
synchronous with the periodical returns of inter- 
mittents, taking place at the accession of the hot 
stage, when in this, as in other disorders in which 
fulness of blood in the vessels of the brain has 
been one of the morbid conditions, the greatest 
danger of injury to that organ, and its conse- 
quences, has been averted by the escape of blood 
from the nose. 

In congestions of blood in other organs of the 
body, whether of an acute or chronic character, 
as in the lungs, but particularly in the liver ; or 
in mechanical obstructions to the free course of 
blood, occasioning its determination to the head, 
or an impediment to its free circulation in this 
organ, the same effect has been attended with the 
same salutary consequences. The suppression of 
the natural secretions of the body is a frequent 
cause of epistaxis. We see it occurring very com- 
monly in araenorrhoea ; in those diseases in which 
the secretions of the other mucous or serous mem- 
branes are suspended ; and not unfrequently when 
the natural function of the skin has been checked 
partially or generally. Morgagni has handed down 
to us the record of an extraordinary, and, as far as 
we know, a snigular instance of the simultaneous 
occurrence of epistaxis in a number of persons :- 
It IS stated that in the year 1200 there was a great 
mortahty of men m the space of twentv-four hours, 

frol^'r"^ 'r 1 ^°"'V't^^' by ^ flux of blood 
from the nostrils; and Morgagni has -Pn^arkerf 



EPISTAXIS. 



93 



that Clcmentini, the historian of Rimini, had noted 
that in the same year a great number of deaths 
from hemorrhage had occurred within four-and- 
twenty l»ours at Rimini, Ravenna, and in other 
cities of the Roman province ; hut from what part 
of the body is not mentioned. Various conditions 
of the atmosphere, it is well known, have a power- 
ful effect on the expansive quality of the blood, as 
well as of other fluids : besides the effect of the 
stimulus of heat, the plethora ad molem is induced 
by the same cause ; it not unfrequently happens 
that passing from a cold into a heated room occa- 
sions this kind of hemorrhage ; and a sudden 
transition in the natural atmosphere occasioned, 
it is probable, the endemic we have just noticed. 
The same expansive quality of the blood is evinced 
by alterations of the atmospheric pressure ; and in 
the ascent of high mountains an early physical 
consequence has been a flow of blood from the 
nose, increasing in proportion to the altitude, and 
succeeded by hemorrhage from the ears and lungs, 
as well as by other very alarming symptoms. We 
have an interesting example of this in the enter- 
prising traveller Saussure, on the occasion of his 
celebrated ascent of Mont Blanc. 

The passive or atonic epistaxis takes place only 
in those extreme states of depression of the vital 
powers, which occasionally occur after the inflam- 
matory stages of fever have passed by, or in such 
as have been considered of a putrescent tendency, 
as in the advanced state of eruptive fevers, parti- 
cularly of malignant small-pox and scarlatina. In 
cachectic diseases, such as the purpura hemor- 
rhagica, scorbutus, and certain broken-down states 
of the constitution, consequent to visceral disease 
of a chronic kind, particularly that of the liver, 
arising from the long-continued influence of a hot 
climate, or the habitual intemperate use of spirituous 
liquors, the atonic epistaxis is occasionally a very 
troublesome and dangerous symptom. 

Instances have been recorded of the loss of al- 
most incredible quantities of blood from the ves- 
sels of the nose. Ten, twelve, and upwards of 
twenty pounds have been known to flow away 
before the hemorrhage has ceased. " Bartholin 
mentions a case of forty-eight pounds, Rhodius 
another of eighteen pounds lost within thirty-six 
hours ; and a respectable writer in the Leipsic 
Acta Erudita, a third, of not less than seventy- 
five pounds within ten days, which is most proba- 
bly nearly three times as much as the patient pos- 
sessed in his entire body at the time the hemorrhage 
commenced." In the Ephem. Nat. Curios, is a 
case " in which the quantity indeed is not given, 
probably from the difficulty of taking an account 
of it, but which continued without cessation for 
six weeks." (Good's Study of Medicine.) 

The active or entonic epistaxis is usually pre- 
ceded by a sense of weight and fulness in the 
forehead and face, frequent flushing in the latter, 
with heat and itching in the nose ; a remarkable 
degree of throbbing is often experienced in the 
temporal arteries, a ringing in the ears, and some- 
times a dull or indistinct sense of hearing; but in 
many instances no precursory symptom is ob- 
served, and the blood issues forth suddenly, with 
various degrees of force. 

Passive or atonic epistaxis occurs, in general, 
without any preceding indication peculiar to it ; 



and in many instances, particularly in the ady- 
namic states consequent on fevers, it is not unfre- 
quently accompanied with entire insensibility. In 
the cachectic states of the constitution giving rise 
to this kind of epistaxis, inordinate and uncontrol- 
lable losses of blood from the nose have most 
commonly taken place, and therefore have beer? 
more frequently the objects of attention in advancec' 
than in early life. 

Entonic epistaxis is always to be regarded as ap 
indication of the urgent necessity for the systen> 
of the blood-vessels of the head to be relieved of 
a superabundance of this fluid ; and so long ar 
this condition lasts, it ought to be encouraged, o> 
at least on no account restrained by direct suppres 
sion. It is often observed that the evacuation of 
a small quantity of blood from the vessels of thi^ 
organ is the spontaneous cure of a severe head 
ach, or relieves an oppressed state of the brain 
dependent on preternatural fulness of its blood 
vessels ; and it is probable that apoplexies and 
other dangerous diseases of this organ have not 
unfrequently been stayed, if not entirely prevent- 
ed, by this natural method of cure. In advanced 
life, however advantageous this hemorrhage proves 
under an immediate threat of such forms of dis- 
ease, we must bear in mind that it is an indication 
of an altered condition of the blood-vessels of the 
head, which pathologists have observed progres- 
sively to increase in the majority of persons after 
the middle period of life, and that it is often, on 
this account probably, the precursor of fatal apo- 
plexies, epilepsies, palsies, and other cerebral dis- 
eases. 

In a practical view we may consider epistaxis, 
in reference to the condition of the various organs 
of the body, and the positive disease (if any) with 
which it is accompanied, in the same light as arti- 
ficial bloodletting, always remembering the im- 
portance and delicacy of the organ to which a 
determination is already established, or probably 
would be, if the exit of blood from the ramifica- 
tions of the vessels supplying the nose were pre- 
vented : such diseases and conditions will require 
their peculiar kinds of treatment, and the avoid- 
ance of the exciting causes which produce this 
particular affection. It occasionally happens, how- 
ever, that this evacuation is excessive at a single 
occurrence ; or that by its continuance a passive 
state of the vessels is induced ; or sometimes, in- 
dependently of plethora, the evacuation becomes, 
by frequent recurrence, habitual, and, if not ar- 
rested, would be productive of consequences dan- 
gerous to life. 

The particular treatment necessary to prevent 
an excessive or habitual epistaxis of the entonic 
kind is founded on two principles; 1st, diverting 
the determination of blood from the vessels of the 
head to other parts of the body ; and, 2dly, the 
direct application of those means which are cal- 
culated to act on the extremities of the vessels 
themselves ; which means consist of astringei. 
substances and mechanical compression 

The former includes the various remedies which 
are comprehended in the antiphlogistic regimen, 
those being selected which are adapted to restoit 
the particular function which may in each case 
have been suspended, and to produce a counter 
balancing excitation in a system of vessels at « 



94 



E P I S T A X I S , 



distance from the already overloaded vessels of the 
nares and head : hence the use of purgatives is 
particularlv indicated ; and in very plethoric habits 
a combination of such as stimulate the tract of 
the alvinc canal, as well as excite its watery secre- 
tions, will be found advantageous. 

Bleeding, also, from a vein in the arm or foot, 
or topical bleeding by leeches applied to the head, 
or by cupping on the nape of the neck, will be 
requisite in some cases in which the hemorrhage 
from the vessels of the nose may have been so 
small as to point out only the necessity of such an 
evacuation, but not sufficient to remove the occa- 
sion of it, and the symptoms with which it is ac- 
companied. In habitual epistaxis, also, we shall 
find the necessity often of thus artificially changing 
the distribution of blood, and, by anticipating the 
periods of the return of this morbid disposition by 
proportionate bleeding, may at length be enabled 
altogether to prevent it. 

Emetics have been occasionally of service, and 
are recommended by Stoll, on the principle of 
relaxing the capillaries; but unless epistaxis should 
appear to depend on an inordinate fulness of the 
stomach, impeding the due course of the blood in 
the large vessels, we should be wary in having 
recourse to them, for the very action they induce 
is an impediment to the free circulation of blood 
in the vessels which it is our object to relieve, and 
has occasionally been the cause of the affection 
which -is to be removed. Sprinkling cold water 
on the face will often have a powerful effect in the 
suppression of this kind of hemorrhage, and even 
immersion of the whole head has been successful 
when other remedies have failed. A striking in- 
stance illustrative of this is recorded by Dr. Dar- 
win, in his Zoonomia ; the patient was a lady who 
had epistaxis for several days from a part of the 
nose to which the attempt to apply mechanical 
compression had failed, and in whom, from a pre- 
ternatural sensibility of the pharynx, it was found 
impossible to stop up the posterior nares : vene- 
section and the other usual remedies had been tried 
in vain : but by immersion of the head in a pail 
of wafer, rendered colder by the liquefaction of 
some common salt, the hemorrhage was checked, 
and did not return ; but hardness of the pulse 
continuing, loss of blood from the arm on the fol- 
lowing day was resorted to as a requisite precau- 
tionary measure. 

Dashing cold water on the genitals has some- 
times had an instantaneous effect in the suppres- 
sion of epistaxis. In the same manner, the popu- 
lar remedy of applying a large key or other piece 
of cold metal between the clothes and the surface 
of the back has caused it to cease. The exposure 
of the face to cold air, the observance of an erect 
position, with an inclination of the head back- 
wards, cold drinks, and the application of cold 
water or ice to the nose, will often be sufficient to 
terminate this hemorrhage. 

If these means, however, should fail, the nostril 
from which the blood issues should be stopped 
with a piece of lint or other soft substance, so that 
the retarded blood may coagulate, and thus pro- 
duce pressure against the ruptured vessel: if this 
should not succeed, recourse must be had to 
astringents in preference to methods of compres- 
«! -.r. to be presently described, and which, though 



perhaps more certain, are extremely disagreeable 
in their application, and need be resorted to only 
under urgent circumstances. Astringent applica- 
tions may be used in the form of an injection with 
a syringe; or that of powder, carefully blown into 
the nostril through a quill: the method of inhaling 
them by an inspiratory action, as commonly ad- 
vised, is apt to disturb any portion of coagulum 
that may be already formed, or to increase the 
excitation of the ruptured vessel itself. A variety 
of astringent applications have been recommended 
for the suppression of epistaxis ; those most in 
use are vinegar and water, dilute mixtures of sul- 
phuric acid with water or spirits of wine, spirits 
of wine alone, tincture of benzoin, solutions of 
alum, of the metallic salts, &c. ; the two last men- 
tioned are chiefly to be relied on, and should 
always be preferred. Two drachms of alum, or 
from two scruples to a drachm of sulphate of zinc, 
dissolved in half a pint of distilled water, or the 
solution of the acetate of zinc of the Edinburgh 
Pharmacopoeia, or a drachm and a half of the 
muriated tincture of iron, diluted with six ounces 
of water, will be suitable injections for this pur- 
pose : the common solution, also, of the acetate 
of lead, or the same salt in a much less diluted 
state, may also be used for the same purpose, after 
which a piece of lint, imbued with whichever of 
the solutions may have been preferred, should be 
passed up the nostril with a probe, or some such 
instrument, so that firm compression may be 
effected. 

The powders to be used in the manner we 
have already stated, ought to be finely levigated ; 
hut even in this state the irritation they are apt to 
excite may be productive of consequences which 
would more than counterbalance the advantages 
to be expected from their astringent quality. The 
sulphate of alum and powder of galls have been 
usually preferred ; a powerful styptic has also 
been found in charcoal, either used in the form of 
powder, or mixed with water and appUed as a 
paste on a tent of lint. An instance of the suc- 
cessful use of the powder of gum acacia blown 
into the nostril in a case of epistaxis, which had 
continued for two days, and had resisted the other 
means generally adopted, has been transcribed 
from Hufeland's Journal into the 27th volume of 
the Medical Repository. A.s this substance is not 
only free from the objection we have mentioned to 
astringent powders, but congenial to the sensibility 
of the Schneiderian membrane, and probably pro- 
duces its good effect simply by increasing the 
tenacity and adhesive quality of the blood on its 
issue from the extremity of the bleeding vessel, it 
appears to us that in some cases it may be an 
eligible application. 

8hould the practitioner be baffled in his at- 
tempts with the means above suggested, or should 
the unsuccessful use of one astringent give little 
promise of advantage from another, direct com- 
pression may be made by passing a long piece of 
catgut from the anterior aperture of the nostril 
which is the source of the hemorrhage, so far into 
the pharynx, that by a pair of forceps it may be 
drawn into the mouth, in order that a piece of 
cotton or lint may be attached to it, of sufficient 
thickness to press against the parietes of the canal 
again rt traded : this being 



when the catgut is 



EPISTAXIS. 



95 



done, it is to be separated from the lint or cotton, 
which is allowed to remain in the canal until fur- 
ther means shall have had the effect of suppressing 
the hemorrhagic tendency. Such is the method 
generally recommended by surgical writers, but 
the irritation excited on putting it into practice, 
and, when effected, the aversion expressed by 
patients to its endurance, are so great, that, what- 
ever the danger may be, they will rarely submit to 
or suffer its continuance for a sufficient length of 
time ; and it must be acknowledged that there is 
some hazard that its removal may prove a fresh 
cause of excitement. A great surgical authority 
(Mr. Abernethy), with his accustomed humour, 
has fold us that he knew that such a method 
could be adopted, for he had seen it done ; but 
that whenever he had tried to do it he always 
failed, finding an obstacle in the excessive irrita- 
tion produced in the muscles of the pharynx : but 
the same authority has observed that he had never 
seen an instance of epistaxis which could not be 
suppressed, (and that he had seen a great many 
instances,) by the introduction of a cylindrical 
plug of lint through the anterior nares, made suf- 
ficiently large to fill the tubular part of the nostril, 
being first wetted and wound round a prohe, so as 
to give it the form of a bougie, long enough to 
allow it to be passed along the floor of the nose 
from the anterior to the posterior aperture, but not 
into the throat ; the probe being withdrawn when 
the lint has been thus disposed of. This plug 
should be allowed to remain in three or four days, 
while the proper means are taken to remove the 
causes of the occurrence of the hemorrhage. 

The after treatment, which is usually of more 
importance than the immediate suppression of 
nasal hemorrhage, for the latter will frequently 
cease as soon as it is desirable that it should do 
so, consists in the pursuance of the antiphlogistic 
regimen to a degree commensurate with the ur- 
gency of the general symptoms and state of the 
body. It is necessary to consider how far it may 
be safe to regard the recurrence of an attack as the 
salutary consequence of the impeded function of a 
particular organ, or other co-existent disease; and 
how far, also, it may be reasonable to anticipate 
the practicabihty of the restoration of the one or 
the cure of the other, on which the hemorrhage 
may depend, without the hazard of a further loss 
of blood, if it should happen, exceeding the neces- 
sity of the system, or being otherwise disadvan- 
tageous to the circumstances of the patient. 

We deem it superfluous to enter into a detail 
of the antiphlogistic means to be adopted ; the 
general condition of the system affording the best 
indication of the extent of reduction which may be 
necessary. It will be evident that the causes 
which excite the attacks in the first instance must 
be avoided as those likely to promote their recur- 
rence. The observations already made as to arti- 
ficial bloodletting, purgatives, and emetics, will 
also be applicable to the state we are now con- 
sidering. It may nevertheless be necessary to 
diminish the action of the heart and arteries fur- 
ther than it would be prudent to attempt by greater 
abstraction of blood, as well as to oppose the re- 
acti-ve tendency which may exist when this remedy 
has been adopted. In digitalis, or nauseating 
doses of tartrate of antimonv, thp suitablo mearv? 



will be found : one or both of these may be com- 
bined with the common diaphoretic saline draught 
and nitre, or other excitants of the skin and kidneys. 
When this hemorrhage, either from long con- 
tinuance or habit, has induced an atonic state of 
the blood-vessels, and a disposition to its inordi- 
nate or frequent recurrence is manifested, the in- 
ternal use of diluted sulphuric acid, or superace- 
tate of lead, may be advantageously had recourse 
to; and whether the hemorrhage be combined 
with an entonic or atonic condition of the body, 
if it have been excessive, or there should be rea- 
son to apprehend that it may prove so, experience 
has shown that either of these astringents will be 
a powerful adjuvant whether to the antiphlogistic 
or tonic plan of treatment, whichever may be 
directed to estal)lish the contractility required in 
the ruptured end of the bleeding vessel from which 
the effusion may have taken place. This consi- 
deration leads us to notice a remedy, — the ergot 
of rye, which, from its powerful effect of exciting 
the natural action of the uterus, has been applied 
to a corresponding condition of the blood-vessels 
of that organ productive of hemorrhage, and. as it 
appears, with the desired effect : on the same prin- 
ciple it has lately been used in epistaxis ; (Med 
Chir. Rev. July 1831,) and as it was followed by 
its cessation, further experience may determine it 
to be a valuble remedy in this as well as in other 
kinds of hemorrhage in which the bleeding vessejs 
are reduced to an atonic state. Our present ex- 
perience of it, however, in cases of epistaxis is too 
limited to enable us to decide on its eligibility. 

In passive or atonic hemorrhage it is scarcely 
necessary to observe that those means which con- 
stitute the antiphlogistic regimen are inadmissible. 
The general treatment must be adapted to the dis- 
ease, whatever it may be, which exists with this 
affection ; and on some occasions, when the he- 
morrhage is excessive and exhausting, powerful 
stimuli will be required ; a large dose of laudanum, 
with carbonate of ammonia and camphor mixture, 
may be given with advantage under such circum- 
stances ; brandy and water, brandy-gruel, wine, 
strong animal soups, and jellies will also be 
necessary to recruit the exhausted strength of a 
patient, weakened as he must be by the continued 
or repeated drain of this vital fluid, imder circum- 
stances of disease in which debility is a fearful, 
and in many instances an irremediable condition. 
The local treatment consists of the application 
of astringents and the use of compression or stop- 
page by the insertion of lint or cotton, as advised 
in the local treatment of entonic hemorrhage; and 
must be immediately adopted, unless in some pe- 
culiar states of the blood-vessels of the brain, in 
which it is possible that the balance of advantages 
may preponderate in favour of a slight evacuation 
of blood from the vessels of the nose, even though 
they should be in a passive or atonic state; but as 
this occurs in the advanced stages of continued 
and eruptive fevers, or purpura hemorrhagica, oi 
of scorbutus, accompanied with every other symp 
torn of exhaustion, the oozing of blood should be 
restrained as soon as possible. It too often happens, 
however, under such circumstances, that the work 
of death is already begun, and that the arrest of thd 
hemorrhage by mechanical and not vital powe- 
proves but a feeble obstacle to its completion. 



ee 



ERETHISMUS 



[Of late, a mechanical agency has been pro- 
posed for arresting the flow of Wooci, which, it is 
affirmed, is a popular remedy for epistaxis in the 
United States. (Amer. Journ. of the Medical 
Sciences, Jan. and April, 1843.) It has been 
strongly urged on the attention of the profession 
by M. Ncgrier, and has been made by him the 
subject of different communications to the Aca- 
demic des Sciences, of Paris. The patient is made 
to stand up with the head elevated. The nostril 
whence the blood flows is compressed with the 
finger, and the corresponding arm is directed to 
be raised perpendicularly, and to be kept in that 
position for about two minutes. The hemorrhage 
is soon arrested, owing, M. Negrier thinks, to a 
less vigorous circulation through the carotids, re- 
sulting from the increased force required to carry 
on the circulation through the upper extremities 
when raised. Cases have been published by others 
than M. Negrier in which this plan has been suc- 
cessful. M. Negrier has found it equally service- 
able in encephalic hyperaemia, and in cephalalgia 
with somnolency, — whenever, in other words, it 
has been desirable to diminish the flow of blood 
to the head. (Revue Medicate, Juin 1843 ; or 
Amer. Journ. of the Med. Sciences, April 1844, 

P-**^-)^ W.Kerr. 



[EQUINIA. (See Giandkhs.)] 

ERETHISMUS MERCURIALIS, mercurial 
erethism. The word erethismus (from epcBi^u), to 
excite or irritate,) is obviously a generic term 
which may be applied to any kind of morbid sen- 
sibility or irritability ; but it has hitherto been al- 
most exclusively confined to that species of ere- 
thism which sometimes arises from the use of 
mercury, and to which the appropriate name of 
erethismus mercurialis was given by the late sci- 
entific John Pearson, to whom we are indebted 
for the first notice of the disease. Prior to the 
period at which that distinguished surgeon was 
elected to the charge of the Lock Hospital, a year 
seldom elapsed without the occurrence of two or 
three sudden deaths, without any assignable cause, 
among the patients who were undergoing a mer- 
curial course. These were, in truth, cases of 
mercurial erethism, the nature of which was not 
then understood. Mr. Pearson has well described 
the disease as characterized " by great depression 
of strength ; a sense of anxiety about the praecor- 
dia ; irregular action of the heart ; frequent sigh- 
ing ; trembling, partial or universal ; a small, quick, 
and sometimes intermitting pulse ; occasional vo- 
miting ; a pale, contracted countenance ; a sense 
of coldness : but the tongue, (Mr. Pearson adds,) 
is seldom furred, nor are the vital or natural func- 
tions much disordered." This aflTection appears 
to arise from mercury acting as a poison. So great 
is the danger attending this affection in its severer 
form, that any sudden or violent exertion may 
prove immediately fatal. Happily, however, its 
first appearance may be readily detected, and, by 
prompt measures, effectually removed. A tre- 
mulous motion of the tongue, a slight trembling 
in the limbs, or a sense of fluttering within the 
chest, are among the earliest indications of its ap- 
jToach. The pulse becomes feeble, hurried, and 
irregular, sometimes intermitting for several se- 
conds, and then beating with great rapidity. On 



MERCURIALIS — ERYSIPELAS. 

applying the hand to the left side of the chest, the 
heart will be found to act with extreme irregularity. 

'J'his peculiar irritation may arise from the ad- 
ministration of mercury in any form ; and may 
occur during any period of a mercurial course, 
though most commonly at its commencement. 
The exact circumstances which favour its occur- 
rence in the particular individuals attacked have 
not hitherto been ascertained. The writer of this 
article, while resident medical officer of the Lock 
Hospital, has seen it produced by the inunction 
of a single drachm of mercurial ointment, arid re- 
produced, in the same individual, after the discon- 
tinuance of the medicine for a whole month, by 
three frictions, each consisting of only one drachm 
of the ointment. It is remarkable, however, that 
in the greater number of instances, a full and ade- 
quate course of mercury has been afterwards borne, 
without any recurrence of erethismus, by the very 
persons who had suffered from it during the com- 
mencement of the course. 

The treatment of the mercurial erethismus is 
as simple as it is effectual. The open air is the 
grand antidote. As soon as the slightest intima- 
tion of the disease is perceived, the patient should 
be carried into the open air, with as little exertion 
to himself as possible, and there he should remain 
as long as may be practicable. To use Mr. Pear- 
son's words, " he should live there." Mercury, in 
every form, must be immediately discontinued, and 
a mercurial atmosphere carefully shunned. If in- 
unction have been used, the skin should be tho- 
roughly cleansed from any adhering ointment. 
The subcarbonate of ammonia, either with or 
without camphor, is an important auxiliary, and 
may be given in rather full doses, at moderate in- 
tervals, until the circulation becomes more steady, 
and the general power of the system revives. It 
is an important and encouraging fact, that from 
the time at which this treatment was adopted by 
Mr. Pearson, not a single death occurred from ere- 
thismus at the Lock Hospital. 

After an attack of mercurial erethism, great cir- 
cumspection will be needful both as to the time 
of recommencing, and the mode of conducting, the 
mercurial course. In the slighter cases, the dis- 
ease entirely subsides in five or six days, and even 
in the severer forms the mercurial treatment may 
often be safely resumed within a fortnight. Still 
the most watchful care must attend every remain- 
ing step of the course. 

The reader may consult with advantage Pear- 
son's Principles of Surgery, and the observations, 
by the same author, of the different articles on the 
Materia Medica which have been employed in the 

cure of Lues Venerea. rn tt t-> 

T. H. BURDER. 



ER'V SIPEL AS. This term is derived, accord- 
ing to some authors, from tptu), to draw, and TtAof, 
adjoining ,- implying that a disease has a tendency 
to spread to the adjoining portions of the skin. 
Various other derivations have been suggested, but 
that now adopted appears to be the more correct. 
It was termed by the Greeks ipvciitiXa^, by the 
Romans Ignis Sacer, and is known in popular 
language by the name of the Rose, from the colour 
of the skin, and by that of St. Anthony's fire, 
from the burning heat with which it is accom- 
panied. 



ERYSIPELAS. 



97 



Erysipelas may be defined inflammation of the 
skin, either alone, or combined with that of the 
subjacent cellular tissue ; generally, though not 
always, accompanied with vesicular eruption, the 
local alfection being attended by symptomatic fever. 

The confusion and contradiction which have 
existed among practical writers respecting the na- 
ture of erysipelas, have in some measure arisen 
from attempts to found a correct classification of 
its varieties on some unimportant circumstances 
in its progress. For example, Cullen places ery- 
thema and erysipelas, which are certainly only 
modifications of the same disease, under ditTerent 
orders. He classed the former among the Phleg- 
masia;, the latter among the Exanthemata or 
rashes. It is evident, however, that he was aware 
of their identity, as he laid down their diagnosis 
with great accuracy in the following passage. 
" When the disease is an affection of the skin 
alone, and very little of the whole system, or when 
the affection of the system is only symptomatical 
of the external inflammation, I shall give the dis- 
ease the name of erythema ; but when the external 
inflammation is an exanthema, and symptomatical 
of an affection of the whole system, I shall then 
name the disease erysipelas." (First Lines of the 
Practice of Physic, sec. 274.) If Cullen intended to 
apply the characters of his order Exanthemata to ery- 
sipelas, it must be observed that it does not corres- 
pond in its most important features with this order. 

Willan (On Cutaneous Diseases, Order iii. Ge- 
nus 6, and Order iv. Genus 1,) and Bateman 
(Practical Synopsis, pp. 117 and 124,) classified 
erythema and erysipelas according to their occa- 
sional external characters. Thus erythema is 
placed among the Exanthemata, and erysipelas 
among the Builse. This classification would be 
less exceptionable were vesication an invariable 
accompaniment of the cutaneous inflammation ; 
but when we consider the occasional absence of 
this symptom in erysipelas, it is clear that any no- 
sological arrangement founded on an appearance 
which is not invariably observed, can only lead to 
confusion and misapprehension. 

.1. P. Frank (De Curandis Hominum Morbis, 
Lib. iii.) has adopted Cullen's classification as to 
erysipelas, but includes erythema among the Im- 
petigines, while Rayer, (Traite des Maladies de la 
Peau,) after grouping together erythema and ery- 
sipelas, places them among the Exanthemata. 
Mr. Lawrence (Med. Chir. Trans, vol. 14,) con- 
siders erysipelas to be inflammation of the skin, 
but that like other inflammations it varies in de- 
gree. When it affects the surface of the skin, 
which is red, not sensibly swollen, and without 
vesication, it constitutes erythema. When the 
inflammation is more violent, so as to produce 
swelling of the skin, or in still more severe cases, 
when the cellular and adipose membrane, as well 
as the skin, become inflamed, he designates the 
disease erysipelas. 

Varieties of erysipelas. — The various forms 
of erysipelas depend on the degree of the local in- 
flammation, the type of the accompanying fever, 
and on particular circumstances with which the 
case may be complicated. A full account of the 
varieties of this disease will be found in the article 
Ektthema. 

Various divisions of erysipelas have been pro- 

VoL. II. — 13 I 



posed. Some writers, as Burscrius, have founded 
distinctions on its supposed causes. This author 
divides it into three species : 1. primary or idio- 
pcttkk ; that is, arising spontaneously from an 
internal cause, not preceded by any other disease ; 

2. symptomatic or secondary, supervening on 
another disease, by which its progress is influ- 
enced ; 3. accidental, when it is excited by some 
obvious external cause. 

Others, again, have divided the disease into 
idiopathic, (from an internal cause,) and trauma- 
tic (from an external wound.) Later writers 
have introduced subdivisions from differences in 
the degree of local inflammation. This seems to 
have been the ground of Willan's and Batcman's 
classification: viz. 1. phlegmonous,- 2. (Edema- 
tous ; 3. gangrenous ; to which they add, 4. erra- 
tic, (migratory.) 

Another distinction has been made, according 
as the disease appears on different regions of the 
body, viz., erysipelas of the face and head, of the 
trunk, and of the extremities. 

We shall describe three forms or varieties: 1. 
simple erysipelas ; 2. phlegmonous erysipelas ,• 

3. asdematous erysipelas ; and afterwards point 
out some diflcrences depending on its situation 
on the several regions of the body. 

1. Simple erysipelas. — In this, which is the 
mildest form of the disease, the inflammation is 
confined to the skin, which is hot, smooth, red, and 
shining ; the colour varying from a bright scarlet 
to the more deep rosy or livid tint. 

The swelling is either so inconsiderable as to 
be scarcely perceptible, or, when the inflammation 
is in a greater degree, an evident tumefaction is 
felt on passing the finger over the inflamed sur- 
face. When the inflammatory action is still more 
considerable, effusion takes place into the subjacent 
cellular tissue ; and when this happens, the swell- 
ing is proportionably increased. The accompa- 
nying pain, which varies according to the intensity 
of the local disorder, is of a pungent burning kind, 
very different from the throbbing or pulsatih pain 
of phlegmon. About the third or fourth day after 
the appearance of the disease, vesications form on 
different parts of the inflamed skin, after which 
there is a sensible diminution of the local suffering. 
The vesicles are sometimes small and numerous ; 
occasionally they are of a larger size, and in a day 
or two either break and discharge their contents, 
or the fluid dries into hard yellow crusts, which 
fall off, leaving the subjacent skin sound, or some- 
times abraded. In very mild cases the local symp- 
toms disappear without vesication or even desqua- 
mation of the cuticle ; more generally, however, 
when the inflammation ceases, the cuticle becomes 
detached, and falls off in successive portions. Al- 
though in by far the greater number of cases the 
disease is thus terminated, in some instances its 
disappearance from one part of the skin, more par- 
ticularly if sudden, is followed by its appearance 
on some other part. When erysipelas shows Ibis 
tendency to metastasis or translation, it constitutes 
the erratic form described by Willan and othei 
authors. In such instances it is important to 
watch the condition of the internal organs, morfe 
particularly if the recession of the erysipelatou<< 
inflammation be followed by symptoms which in 
dicate visceral disease. 



68 



ERYSIPELAS. 



SweJiaur (Nov. Noa. Mcth. Syst. vol. ii.) gives 
the case of a robust plethoric man, 55 years of age, 
who had for many years laboured under paroxysms 
of gout, which returned at stated periods. He 
had been free from his gouty attack for a longer 
period of time than usual. The eyelids became 
suddenly swollen ; two days after, the oedema dis- 
appeared from the palpebrae ; he then complained 
of pain in the throat and difficulty in swallowing. 
This was soon removed by the use of gargles, 
when the oedema of the eyelids returned: in a 
few days afterwards the fingers of the right hand 
became in succession red and swollen, and subse- 
quently ulcerated. The man then recovered. 
After the lapse of some months the disease re- 
turned, and assuming the same migratory course, 
fixed in the feet, where it produced ulceration, on 
the healing of which the patient's health was com- 
pletely restored. 

Frank (De cur. Horn. Morbis, vol. ii.) relates 
the history of a woman in whom erysipelas mi- 
grated from the face to the feet, thence to the hip, 
and afterwards re-appeared on the face. After it 
disappeared from the face, the intestines became 
affected ; soon afterwards she was seized with dis- 
ease successively in the chest and in the brain. 

Willan gives the only case of erratic erysipelas 
which had in his experience proved fatal. A 
labouring man, aged 44, after much fatigue and 
exposure to cold, became afiected with cough, 
shortness of breath, and febrile symptoms. Five 
days afterwards an erysipelatous patch appeared 
on his left shoulder, and another on the left leg. 
On the seventh day, similar patches appeared 
above and below the knees. On the eighth day 
the eyelids became tumid and red. About this 
time the other swelUngs assumed a livid hue, the 
febrile symptoms increased, and were attended 
with deafness and coma. On the ninth day the 
tumour of the right eye extended to the temple, 
upon which small phlycteuiB soon after formed. 
On the eleventh and twelfth the patient seemed 
totally insensible ; his pulse became feeble and 
irregular, and he died on the following day. (Wil- 
lan on Cutaneous Diseases.) 

2. Phlegmonous erysipelas In this form the 

inflammation affects the skin and the subjacent 
cellular and adipose tissues, and generally termi- 
nates in suppuration, and even sloughing of the 
affected parts. It generally occurs in young ple- 
thoric persons ; those in more advanced life, how- 
ever, are not unfrequently the subjects of it, though 
its progress is more rapid and its duration shorter, 
in young than in elderly people. 

Phlegmonous erysipelas appears more frequently 
on the extremities than on any other part of the 
body. The fever with which it is accompanied is 
of the inflammatory character ; and occasionally 
symptoms of gastric disturbance arise, either at 
the beginning or during its progress. The redness 
of the skin is of a deep tint, and, as in other forms 
of erysipelas, disappears on pressure. The pain is 
severe, and accompanied with <v sensation of burn- 
ing heat, while, in consequence of the effusion 
which takes place into the subcutaneous cellular 
lueraurane, the affected parts communicate a pecu- 
liar feeling which has been expressed by the term 
brawny. 

When the disease has gone on for four or five 



days, vesications appear, and go through the sarae 
changes as in simple erysipelas; or sometimes, 
instead of this process, desquamation of the cuticle 
takes place. The redness then declines, the skin 
assumes a yellow tinge, the swelling and febrile 
symptoms gradually subside, and the disease may 
thus end in resolution. This favourable termina- 
tion is by no means common. Phlegmonous 
erysipelas more commonly ends in suppuration, 
and even in gangrene, the purulent matter in the 
former case being either confined in small ab- 
scesses, or diffused in the cellular membrane. 

When gangrene takes place, the cellular mem- 
brane becomes completely disorganized, and, ac- 
cording to the description of Mr. Lawrence, appears 
like a dirty spongy substance filled with turbid 
fluid ; then losing its vitality altogether, it is con- 
verted into more or less considerable fibrous shreds 
of various size and figure, which come away, 
soaked with matter like a sponge ; while the inte- 
guments, being deprived of their vascular supply, 
become hvid, and often lose their vitality. When 
these changes take place, the tension of the pre- 
vious inflammatory stage is succeeded by a pecu- 
liar softness ; the sensation thus imparted has been 
compared to that excited by a quagmire or morass, 
and hence the term boggy has been given to it. 

When an entire Hmb is affected with phlegmon- 
ous erysipelas, the inflammation and subsequent 
disorganization of the cellular tissue is not con- 
fined to that portion which is immediately under 
the skin, but extends to the intermuscular stratum. 
Should the patient survive such an attack, the 
skin, fascia, muscles, tendons, and bones, as stated 
by Mr. Lawrence, are so agglutinated and fixed, 
after the extensive destruction of the connecting 
cellular tissue, that the motions of the part are 
permanently and seriously impaired. 

Various morbid appearances in the internal 
organs have been discovered in fatal cases of 
phlegmonous erysipelas. These organic inflam- 
mations, which were evidently the more immediate 
cause of death, have been often unaccompanied 
by symptoms by which their existence during life 
could be ascertained. 

3. (Edematous erysipelas. — This species, which 
may be said to be intermediate between the simple 
and phlegmonous, is observed chiefly in persons 
of impaired constitution, or in those who have a 
tendency to dropsical effusion. The skin, which 
is of a pale red colour, inclining to a yellowish 
brown, is smooth and shining, but less hot and 
painful than in the other forms. The inflamma- 
tion is of the sub-acute kind, and gives rise to 
serous eflusion ; the swelling extends slowly and 
gradually, leaving the impression of the finger as 
in anasarca, from which circumstance this form 
has received its distinctive appellation. In the 
more acute cases thin purulent matter is often 
mixed with the serosity. Vesications are less 
commonly observed in oedematous erysipelas, and 
the vesicles are smaller, less elevated, and more 
numerous than in either the simple or phlegmon- 
ous forms. 

It is very liable in some situations to terminate 
in gangrene; this is announced by the redness 
changing to a livid hue, and by the cessation of 
pain. Hence, when erysipelas appears on the 
genital organs, or on dropsical limbs, when the 



ERYSIPELAS. 



99 



skin is much distended, or when punctures have 
been m^ide with the intention of allowing the 
fluid to drain ofl", gangrene frequently supervenes. 
When, therefore, it is deemed advisable to punc- 
ture dropsical parts, the best mode of preventing 
such consequences is to insert a fine couching 
needle under the skin at short distances. This 
mode has been found preferable to making small 
incisions with the l-incet, in so far as it is seldom 
followed by erysipelas. 

4. We shall next advert to some differences in 
the local and general symptoms of erysipelas, de- 
pending in some measure on the situation of the 
part on which it appears. It is a matter of daily 
observation, that when erysipelas occurs on the 
extremities, it is less severe than when it appears 
on the trunk ; it is almost invariably confined to 
one limb, and seldom attended with danger, un- 
less, from its proximity to any of the larger joints, 
articular inflammation arises, which may termi- 
nate in efl'usion, or some other consequence of sy- 
novial inflammation. 

In no region of the body is erysipelas more for- 
midable and dangerous than on the face and scalp. 
The severity arises chiefly from the inflammation 
of the brain or its membranes, which almost inva- 
riably supervenes. Erysipelas of the face or scalp 
(to which the name sideruiio has been given) is 
preceded hy two or three days' smart febrile indis- 
position. The redness appears on some part of 
the face, from which it gradually spreads: it is 
sometimes confined entirely to the side of the face 
in which it first appeared ; but more generally it 
is diffused over the whole face, forehead, and 
scalp ; and occasionally creeping down the neck, 
extends to the shoulders and trunk. In other 
cases it first appears round some slight wound, 
such as those made by leeches or by the cupping 
scarificator, or around the margin of a blister : 
sometimes it succeeds to an external injury of a 
more severe kind, a lacerated or contused wound 
of the scalp. As the disease advances, the face, 
and more particularly the eyelids, become swollen ; 
the vessels of the head pulsate strongly ; delirium, 
at first transient, but afterwards constant, comes 
on, succeeded by drowsiness, or coma; vesications 
or desquamation ot the cuticle take place about 
the fourth day, after which the local and general 
symptoms abate : in more severe cases, however, 
the symptoms in the brain increase ; the delirium 
increases ; the patient either becomes furious, or 
falls into a state of perfect insensibility, and after 
lingering till the tenth or twelfth day, dies from 
the effects of cerebral inflammation. In other in- 
stances, in which the brain afltction has been less 
intense, external abscesses form, most frequently 
on the eyelids : occasionally the matter becomes 
diff'used in the cellular tissue of the scalp, or when 
the inflammation has terminated in gangrene, 
sloughing of this membrane takes place, the peri- 
cranium being often detached, to some extent, from 
the cranial bones. The parotid and cervical glands 
become inflamed in severe cases, and not unfre- 
quently abscesses form in the cellular tissue in 
which they are embedded. 

It is necessary to notice a form of pharyngeal 
inflammation which has been observed when ery- 
sipelas is prevalent at certain seasons, or appears 
in some localities as an enidemic. Some have de- 



scribed this affection as erysipelatous inflammation 
of the throat ; and although this) term conveys a 
pretty accurate idea of the nature of the disease, 
we think the application of the term erysipelas 
to inflammation of mucous membranes incorrect, 
inasmuch as the term ought to be restricted to 
cutaneous inflammation. In the affection to which 
we allude, though there is fever, and pain in the 
throat, especially on deglutition, there is little 
swelling, but general redness of the fauces. 

Dr. Stevenson, (Med. Chir. Trans, of Edin. vol. 
ii.) who has given a condensed but good descrip- 
tion of the disease as it appeared at Arbroath, 
states that in some cases the inflammation was 
confined to the fauces ; in a few, however, it spread 
to the larynx, producing symptoms very like idio- 
pathic croup ; in others it extended to the pharynx 
and oesophagus, when he remarked that though 
fluids and solids could be partially swallowed with- 
out much apparent difficulty, after a few seconds 
the patient felt pain in the gullet, followed by in- 
verted action and partial or complete rejection of 
the food. In the more protracted cases, swelling 
and suppuration of the cervical glands took place. 
It has been also remarked, that while in some in- 
dividuals this affection was confined to the throat, 
in others, after commencing in the fauces, the in- 
flammation spread to the face and head, giving 
rise to erysipelas when the cutaneous structure 
became affected. This circumstance, and the oc- 
currence of this affection of the throat at the time 
when erysipelas was prevalent, besides the fact 
that in erysipelas of the face the inflammation 
frequently spreads from the face to the mucous 
cavities of the nose and mouth, show that the 
diseases are essentially the same, modified only 
by the difference of the structure in which they 
occur. 

In the London Fever Hospital, as well as in 
general hospitals, erysipelas is by no means un- 
common. Of protracted cases of malignant fever 
especially, it is a frequent and dangerous conse- 
quence ; and we have occasionally observed that 
the inflammation commenced and was confined 
entirely to the throat : more generally, tyjwever, 
the inflammation, after begitming in the throat, 
has spread from the mouth to the cheek and face, 
or through the nostrils to the nose, and thus ery- 
sipelas has been propagated to the face and head. 
When this form of pharyngeal inflammation is 
confined to the throat, it appears to us to be in 
some measure allied to the Diphtherite of which 
Bretonneau has given an excellent description. 
There is, however, no pellicular or membranous 
exudation, which forms the characteristic distinc- 
tion of diphtherite — indeed, in several fatal cases, 
in which this pharyngeal inflammation was com- 
bined with erysipelas of the face and head, we 
have found scarcely any traces of the previous 
existence of inflammation. There cannot, how- 
ever, be the slightest doubt of the inflammatory 
nature of the affection we are now describing, 
though it does not induce any of the morbid pro 
ducts of inflammation. 

Although erysipelas seldom appears before thn 
age of puberty, a €«vere form of it occasionally 
occurs in infants a few days after birth, sometimes, 
however, so late as the eighth or ninth week 
Infantile erysipelas, as it is termed, is mo>-<? com 



100 



ERYSIPELAS. 



mon in lying-in hospitals than in private practice. 
It appears first on the lower part of the abdomen, 
or on the genital organs, and gradually extends 
down the thighs. The skin is not much swollen, 
but becomes hard and of a dark red or livid colour: 
vesication and gangrene follow, and the genitals 
are not unfrequently entirely destroyed. This 
form of erysipelas generally terminates fatally. A 
milder species is occasionally observed in the 
hands and feet, and sometimes about the neck or 
face. It generally lasts twelve or fourteen days, 
and then disappears, though sometimes it termi- 
nates by suppuration and the formation of small 
abscesses. 

Nature of Erysipelas. — Great diversity of 
opinion has prevailed as to the true pathology of 
this disease, and consequently as to the mode of 
treatment to be pursued. The ancients attributed 
this, in common with every acute disease, to sup- 
posed acrimony of the fluids, which idea was 
apparently strengthened by the vesication which 
frequently arises in its progress, as well as its 
occasional termination in effusion, suppuration, or 
gangrene. The more rational and consistent 
views of pathology which the doctrines of solidism 
introduced, have tended in a great measure to 
throw discredit on the application of the humoral 
pathology to erysipelas. 

From the history and progress of the disease 
which we have laid before the reader, the acute 
nature of er3'sipelas is apparent. We have seen 
in the local symptoms the most satisfactory proofs 
of inflammatory action — redness, heat, pain, and 
swelling : moreover, if we trace its termination in 
resolution, effusion, suppuration, and gangrene, 
the conclusion, according to the soundest princi- 
ples of pathology, is, that wherever erysipelas 
appears, there is inflammation of the skin, or of 
the cutaneous and cellular tissue combined. 

If we advert to the general or constitutional 
s)'mptoms, we find they are exactly proportionate 
to the extent and intensity of the local affection. 
Again, we have stated, that in the more severe 
instances of phlegmonous erysipelas, inflamma- 
tions of internal organs arise ; and if the opinion 
of M. Ribes be correct, that in erysipelas the 
internal tunic of the veins and arteries of the 
integuments is inflamed, and that these vessels 
occasionally contain pus, we have a further corro- 
boration of the inflammatory nature of the disease. 
It must, however, be kept in mind, that in one 
case the cutaneous inflammation may be so trivial 
as scarcely to produce disturbance in the system ; 
in a second, the local symptoms are more severe, 
and accompanied with corresponding general 
excitement ; in a third, the local symptoms may 
be acute, but the powers of the patient may be 
feeble, or the fever with which they are accompa- 
nied of the low or typhoid form. To us it appears 
that the conflicting and very opposite opinions 
which have been and still arc entertained of the 
nature of erysipelas, would be brought to harmo- 
nize if more attention were paid to the prevailing 
character or type of the disease, the duration or 
stage when the practitioner is consulted, the age 
and individual peculiarities of the patient, and the 
treatment which has been adopted in the early 
commencement of the disease. 

Though in the majority of instances the symp- 



tomatic fever is acute, such as always accompanies 
inflammatory diseases, yet, in many cases, e.spe- 
cially in the aged, in persons addicted to uiteni- 
perance, in those who arc the subjects of organic 

jisease or when erysipelatous inflammation 

supervenes on protracted convalescence — more- 
over, at certain seasons or in particular years,— 
the local symptoms arc attended with a low form 
of fever, which does not well bear active depletion, 
the modified antiphlogistic treatment being more 
successful. Indeed, as the disease advances, more 
generous diet, and, in some instances, the employ- 
ment of stimulants, is found necessary. 

This low symptomatic fever, however, is only 
occasionally observed ; it forms the exception, not 
the rule, and leads to the practical inference, that 
this disease cannot be successfully treated upon 
one invariable principle ; that the various circum- 
stances pointed out should be kept in mind before 
we decide on its precise nature, and the line of 
treatment to be pursued. If the practitioner acts 
with the caution suggested, keeping in mind the 
principles we have laid down, he will seldom fail 
to form a proper judgment of any case he may be 
called on to treat. In fact, such variations of type 
are not peculiar to erysipelas ; they are constantly 
observed in all febrile diseases. Epidemic fever, 
small-pox, measles, and scarlet-fever, vary much 
in their symptoms and general aspect at different 
times. 

[There is great reason to regard erysipelas as an 
eruptive fever, and, consequently, a constitutional 
disorder, and, as such, it has been classed by the 
writer elsewhere : (^Practice of Medicine, 2d edit, 
ii. 545, Philad. 1844. See, also, Alison's Out- 
lines of Pathology and Practice of Med. Amer. 
edit. p. 276, Philad. 1844.) Local inflammation 
of a diffuse kind can, doubtless, be occasioned at 
ail times by the application of certain irritants ; 
but there is propriety in separating these purely 
local affections, and classing them under erythema. 
Whilst erysipelas is made to include the constitu- 
tional affection, — that, in other vs'ords, which does 
not occur unless under favouring conditions of the 
system, — which give occasion to the development 
of the exanthem in one person under influences that 
would be wholly inoperative in another. Such is 
the view of M. Chome!, who maintains, "that 
erysipelas is never the result of an external cause; 
or, at least, if an external cause concur in its pro- 
duction, it has but a secondary agency in its de- 
velopment. There must be the concurrence of an 
internal cause of a particular predisposition 
unknown to us."] 

Causes. — It is in most instances diflicult to 
trace the exciting causes of erysipelas. When it 
occurs after local injury, we have at once a pro- 
bable reason for the surrounding integuments 
assuming inflammatory action : still, as erysipela- 
tous inflammation does not succeed to external 
injury in every case, some other circumstances 
must concur to induce it in those instances in 
which it succeeds to accidents or operations. 
There is in many persons a disposition to inflam- 
mation of the skin on the most trivial irritation ; 
in such there is, no doubt, some peculiarity in the 
vascular system of the integuments ; so that any 
causes which excite the circulation either generally 
or locally, may induce erysipelas. 



ERYSIPELAS. 



101 



It is frequently dependent on gastric derange- 
ment, and from the intimate sympathy which 
exists between the skin and mucous membranes, 
irritation of the stomach and bowels may become 
not only a predisposing but an exciting cause, 
especially when there is susceptibility to this dis- 
ease. On the other hand, the irritation in the 
skin during attacks of erysipelas frequently 
induces sympathetic disorder of the biliary and 
gastric system. Hence the origin of the term 
bilious, applied to those cases in which the ery- 
sipelatous inflammation is accompanied with gas- 
tric derangement. 

Some persons, more particularly elderly persons 
of a cachectic habit, and females about the period 
of the cessation of catamenia, are liable to peri- 
odic attacks of the erysipelas, which are generally 
preceded or accompanied by symptoms of derange- 
ment in the stomach and bowels, but seldom with 
fever. When the erysipelatous inflammation in 
such cases appears on the extremities, it sometimes 
induces thickening of the skin, and occasionally 
superficial ulceration, which proves troublesome 
and tedious to heal. 

Besides the origin of erysipelas from causes 
originating within the system itself, it appears to 
prevail more at certain seasons than at others. 
The spring and autumn are the periods of the 
year when it is most prevalent ; it occasionally 
assumes an epidemic or endemic character, from 
which circumstance it has been supposed to be 
engendered by a particular condition of the air, or 
at all events to be materially influenced by atmos- 
pheric causes. 

There have been at various times visitations of 
epidemic erysipelas. It appeared at Toulouse in 
1716, when from its great fatality it was compar- 
ed to the plague. De Haen, (Ratio Medendi) 
Bartholinc, (Hist. Anatom. Rat. Hist. 56) Silvius 
de la Boe, (Prax. Med. Appendix, tract, x.) be- 
sides other writers, describe an epidemic erysipe- 
latous fever, which was accompanied with inflam- 
mation in the stomach and duodeum. 

Bromfield (Surgical Cases and Obsei-vations) 
mentions erysipelas of the head, which was epi- 
demic for two years. Evacuations generally prov- 
ing fatal, it was treated by bark and cordials. 

[An epidemic erysipelas, known by the popular 
name of " Black Tongue," prevailed in some 
parts of Indiana, in the year 1843 ; an account of 
which was given by Dr. Geo. Sutton of Aurora, 
Indiana, ( Western Lancet ; Nov. 1843 ;) and " ery- 
sipelatous fever'' occurred in the Northern sec- 
tion of Vermont and New Hampshire in the years 
1842-3; which has been described by Drs. Charles 
Hall and George J. Dexter, (^Amer. Journ. of the 
Medical Sciences, Jan. 1841,) and by Dr. J. A. 
Allen (Boston Med. and Surg. Journal, 1844.) ] 

When erysipelas is epidemic, it is severe and 
often fatal. The inmates of crowded establish- 
ments, more especially of hospitals for the recep- 
tion of the sick, situated in the vicinity of those 
districts in which it is prevalent, are particularly 
liable to its attacks ; and so long as the epidemic 
prevails, the slightest causes are often sufficient to 
produce the disease. It is, however, more likely 
to occur in those persons whose health has been 
previously broken by protracted diseases. It is 
also a frequent concomitant or consequence of 



fever treated in hospitals, though it rarely occurs 
among fever patients in the better class of society 
When hospital erysipelas once appears in the 
wards, it is most difficult to prevent its spreading ; 
and although it succeeds to operations, wounds, 
or injuries, or supervenes on some slight frritation 
of the skin, as, for instance, around the incision 
made by the lancet in venesection, or by the cup- 
ping scarificator, or appears around the leech-biles, 
or the margin of a blistered surface, it frequently 
arises spontaneously on various regions of the 
body, in patients whose local disease is not ac- 
compajiied by an external wound. It has been 
sometimes so formidable in hospitals, as to render 
it necessary to shut up particular wards, and even 
to delay the performance of surgical operations, 
the most unimportant being at such times follow- 
ed by severe and often fatal erysipelatous inflam- 
mations. 

W^hen erysipelas succeeds to external injuries, 
such as accidents or operations, it may often be 
traced to imprudence on the part of the patient, 
more particularly to errors of diet, or to mental or 
bodily excitement. In many instances the occur- 
rence of erysipelas after operations or injuries, is 
the result of unskilful local or general treatment 
on the part of the surgeon, and more particularly 
of the neglect of the cooling antiphlogistic treat- 
ment during the constitutional excitement which 
generally follows capital operations. 

Erysipelas may also arise from local irritation, 
long-continued or undue pressure, improper exer- 
cise of an inflamed part, or the application of 
stimulants or irritants to sound or ulcerated parts. 

Well-authenticated facts warrant the conclu 
sion, that under certain circumstances erysipelas 
may spread by contagion ; rarely, however, in 
clean and properly ventilated dwellings. It is in 
vain to urge the fact of the disease spreading from 
person to person, as its propagation might be the 
consequence of exposure to the same causes ; but 
when we find persons who, after becoming infect- 
ed apparently from attendance on erysipelatous 
patients, remove as soon as they become ill to 
another residence at some distance, and commu- 
nicate the disease to the family, the irresistible 
conclusion is, that erysipelas in such cases has 
been communicated by contagion. 

Ample proofs of the truth of this opmion will be 
found on reference to the papers of Dr. Wells, 
(Transactions of a Society for the Improvement of 
Medical and Chirurgical knowledge, vol. ji.) Dr. 
Stevenson, (Transactions of the Medical Chirurgi- 
cal Society of Edinburgh, vol. ii.) Dr. Gibson, (Ibid, 
vol. iii.) Mr. Arnot, (London Medical and Physi- 
cal .lournal, March 1827,) Mr. Lawrence, (Medi- 
co-Chirurgical Transactions of London, vol. xiv.) 
and others. A short abstract of the most striking 
facts is subjoined. Dr. Wells was called to attend 
an elderly man with erysipelas of the face, which 
proved fatal. His wife was seized with it a few 
days after his decease, and also died. Five weeks 
after, the landlady, who resided in the same house, 
had erysipelas of the face, but recovered. The 
nurse who attended the landlady was attacked 
with the same disease, and died in the parish 
work-house. The nephew of the person first nl- 
tacked was taken with erysi[)elas shortly afte:; 
visiting his uncle, and died in a few days. 



102 



ERYSIPELAS. 



In another case which subsequently came un- 
der Dr. Wells's observation, the patient had been 
for some time at the bed-side of a female friend 
who had erysipelas of the face, which proved fatal. 
Two sisters of this lady, two servants of the flimi- 
ly, one of whom had acted in the capacity of 
nurse, had all the same disorder. Dr. Wells 
states, in explanation of these facts being regarded 
as indicating only the great prevalence of erysipe- 
las from some general cause, that he saw no more 
than two other instances of the disease during the 
time they happened. 

A person, with erysipelas of the face was 
brought to St. Thomas's Hospital, where he died. 
From inadvertence, another patient having a dif- 
ferent disease was put into the same bed, before it 
was properly aired ; soon afterwards this patient 
had erysipelas of the face. Several other persons 
about this time were attacked with this disease, 
among whom was an upper nurse or sister, to 
whom it proved fatal. 

A lady was attacked with fever immediately 
after dehvery, accompanied with erysipelatous in- 
flammation of the skin. The infant was seized 
three days after birth with erysipelas about the 
pudenda, which spread to other parts of the body 
and even to the face. Both the mother and infant 
died after a few days' illness. The lady's mother 
and servant-maid, both of whom had nursed the 
infant, were seized with erysipelas of the face, 
from which both recovered. 

Dr. Stevenson details briefly the results of 
twenty-one cases of erysipelas, which occurred in 
his practice in 1821-2. It spread, in many in- 
stances, through the members of tjie same family ; 
in some it appeared soon after visiting friends or 
relatives during the period of the disease. A per- 
son who was attacked while in attendance on an 
erysipelatous patient went home to her parents, 
who resided at some distance, as soon as she was 
taken ill : they were soon successively seized, and 
the mother died in a few days. 

In corroboration of these facts, Dr. Gibson 
brings forward other instances which came under 
his observation in 1822. 

A young man with erysipelas of the face, was 
brought to his father's house at the distance of 
some miles. He ultimately recovered. His mas- 
ter had died a few days before of a febrile disease. 
The father of this young man was attacked with 
erysipelas in both hands and arms, which spread 
to the face. He died in a few days. 

The infant son of a gentleman was seized with 
erysipelas on one foot. The mother was after- 
wards seized with erysipelas of the face and scalp. 
The nurse, who suckled the child, was seized with 
symptoms of pneumonia, and was removed to her 
father's house four miles off. Her father, who 
had some days before her arrival received a wound 
of the scalp, was seized with erysipelas of the 
face and scalp, and died soon afterwards. A sister 
living in the same cottage, had fever with sore 
throat, from which she slowly recovered. Two 
children in the same house were cut off with what 
appeared to be croup. The disease in the sister 
and children was no doubt erys pelatous inflam- 
:n3.tion of the fauces and trachea. 

The next case resembles that related in the pa- 
per of Dr. Wells. A woman was admitted into 



the infirmary of Montrose, with suppuration of 
the hand, which had followed an attack of erj'sip. 
clas. Some days after her admission, the patients 
in the two beds next to her were seized with cry- 
sipelas. It was afterwards found that, notwith. 
standing all the patients were removed from that 
ward, and the process of cleansing, white-wash- 
ing, and fumigation adopted, the disease again re- 
appeared when fresh patients were placed in this 
ward, so that it became at length necessary to shut 
up the infirmary for a time. 

Mr. Lawrence mentions an instance in which 
erysipelas of the face, caused by a seton in the 
neck, seems to have aflTected two individuals by 
contagion, producing erysipelas of the face in one, 
and of the lower extremities in the other. 

Diagnosis. — There are few external diseases 
which, from their resemblance to erysipelas, are 
likely to render the diagnosis perplexing. The 
diffused rosy tint of the skin, the uniform swell- 
ing, the peculiar burning pains, the tendency of 
the disease to spread, the vesication or desquama- 
tion of the cuticle, and the undefined suppuration 
and sloughing of the cellular tissue in the ad- 
vanced stages, are sufficient to point out its na- 
ture, and to distinguish it from phlegmon. 

Prognosis* Many general as well as particu- 
lar considerations influence the prognosis. Some 
varieties of the disease are more dangerous than 
others. Simple erysipelas is always a mild disor- 
der ; the phlegmonous and cedematous forms are 
generally severe, often fatal. When the inflam- 
mation is extensive, and terminates in gangrene . 
and sloughing of the skin and cellular membrane, 
the powers of the patient often give way under 
the disease. It is more dangerous in some situ- 
ations of the body than in others ; for instance, 
when it attacks the face and head, there is great 
danger ; when it occurs on the chest or abdomen, 
it is more hazardous than on the extremities. 

As a general rule it is more dangerous in elderly 
than in young persons. Infantile erysipelas is an 
exception to this remark ; this form being ex- 
tremely fatal, more especially that which com- 
mences about the genital organs, and spreads up- 
wards over the abdomen and down the thighs. 

Any disease with which the erysipelatous in- 
flammation is complicated, has an important influ- 
ence on the prognosis. When it occurs in per- 
sons who have organic disease ; when it attacks 
convalescents from long-continued acute affections, 
or those whose strength is exhausted by chronic 
disease ; when it occurs on the extremities of 
dropsical subjects, or after severe injuries or surgi- 
cal operations, the result is doubtful, and therefore 
the prognosis should be guarded. If again, dur- 
ing the progress of the erysipelas, the brain or 
any other important organ become inflamed, more 
especially if the inflammation suddenly leave the 
skin and is followed by symptoms of internal in- 
flammation, there is considerable danger, unless 
the most vigilant treatment be adopted. Hence 
in erysipelas of the head, the state of the brain 
should be minutely watched. Whcu it appears 
on the chest, the pulmonary organs sometimes 
become inflamed; or when it spreads to the 
abdomen, inflammation of the peritoneum or mu- 
cous membrane of the intestines sometimes takes 
placa. 



ERYSIPELAS. 



103 



Lastly, when er)'sipelas prevails epidemically, 
the disease is usually more severe and fatal than 
when it is sporadic. It is also more fatal at cer- 
tain periods than at others, from causes which are 
unknown. 

Treatment. — From the account which has 
been given of the different forms of erysipelas, and 
from the various conditions of the system under 
which it takes place, it is evident that the princi- 
ples of treatment require to be modified according 
to the symptoms and the circumstances of each 
case ; hence it will be proper to consider the age 
of the patient, the state of the general powers, the 
type of the accompanying fever, the seat and in- 
tensity of the erysipelatous inflammation, and par- 
ticularly the duration of the disease. 

It is known from experience, that acute disor- 
ders do not always bear the same treatment; and 
this remark applies equally to erysipelatous in- 
flammation. Hence, at one time, strict antiphlo- 
gistic treatment may be necessary, while at another 
period, the system will not bear the same bold 
measures, although a modification of the same cu- 
rative principles be indicated. Consequently, in 
one case it may be necessary to bleed generally 
and locally, — often to a considerable extent; a 
second may require topical bloodletting only ; in 
a third, the symptoms often yield to mild purging, 
saline medicines, and abstinence ; in a fourth, 
from the depression of the system, it may be ne- 
cessary to administer nourishment and even stimu- 
lants, while at the same time blood is taken from 
the inflamed surface ; in a fifth case, powerful cor- 
dials are required to support the sinking powers. 
It may, however, be affirmed that, in the majority 
of instances, the disease requires antiphlogistic 
treatment.* 

We shall notice^ the measures to be adopted in 
the different varieties of erysipelas. 

1. Simple erysipelas, being only a very slight 
form of cutaneous inflammation, in general yields 
readily to aperients and cooling remedies. If the 
erysipelas appear on the extremities it will be ne- 
cesssary not only to abstain from using the limb, 
but to keep it in the horizontal posture, and to 
avoid any causes of local irritation, more espe- 
cially friction. In some cases it may be necessary 
to apply leeches, and afterwards warm fomenta- 
tions, or a tepid lotion. Puncturing the inflamed 
skin with the point of a lancet is a very good 
mode of local bleeding in slight cases, and may be 
resorted to in preference to the application of 
leeches. 

2. Phlegmonous erysipelas is, of all the forms 
of the disease, the most acute, both as regards the 
local symptoms and the inflammatory type of the 
fever with which it is accompanied. 

The whole aspect of the disease is such as at 
once to indicate the necessity for active measures. 

In general, bloodletting is indispensable ; and 
when the disease occurs in the face and scalp, it 
is necessary to bleed largely and repeatedly till the 
headach and other symptoms denoting cerebral 
affection are removed. Local depletion by cup- 
ping or leeches, and the application of a cold lotion 
to the scalp, will form a good auxiliary to the use 

* Oportt't, si virep patiuntur, sanguinein mittere; de- 
inde imponere simul rcpriiiientia et retVigerantia. — Cel- 
ens de Medicini, lib. v. cap. 25. 



of the lancet, and in some instances may entirelj 
supersede general bloodletting ; indeed, Mr. I/aw 
rence seems disposed to consider the local abstrac- 
tion of blood more serviceable than venesection. 

Active purgatives, antimonial preparations, cool- 
ing drinks, abstinence from animal food of every 
kind, as well as from wine and fermented liquors, 
and quietude of body and mind, constitute the 
general summary of the means to be pursued in 
the commencement of this form of erysipelas. 
This active treatment is required only when the 
patient is young and plethoric, and when the local 
and general excitement is such as to warrant its 
adoption. 

Phlegmonous erysipelas occurs not unfrequently 
in persons advanced in life, or in individuals whose 
powers are feeble ; in such cases, and in the later 
stages of the disease, the active measures just re- 
commended would not only be injudicious but 
positively injurious. In the instances alluded to, 
the local symptoms may exhibit more or less ac- 
tivity, but still the general powers are weak ; topi- 
cal bleeding therefore, if the powers permit, while 
we endeavour to sustain the system by nourish- 
ment and small quantities of cordials, regulating 
at the same time the bowels and the various func- 
tions according to particular indications, will give 
the patient the best chance ot recovery. Cold appli- 
cations, composed of equal parts of diluted alcohol, 
solution of acetate of amraoiiia and of water, or a 
lotion consisting of one drachm of carbonate of 
ammonia and one of superacetate of lead dissolved 
in a pint of rose-water, seem to have considerable 
influence in arresting the processes of effusion and 
suppuration. 

If the erysipelatous inflammation do not yield 
to the active measures recommended, or if the 
practitioner be not consulted till the advanced 
stage of the disease, further depletion will not ar- 
rest its progress, but only exhaust the powers of 
the patient. 

The constitutional excitement which charac- 
terized the early stage of the disease is succeeded 
by marks of impaired energy, while the inflamma- 
tion of the skin and cellular tissue is followed by 
suppuration and sloughing ; and these destructive 
processes not unfrequently extend over the greater 
portion of a limb, purulent matter being infiltrated 
through the subcutaneous cellular tissue. There 
is no outlet for the matter unless by sloughing of 
the skin. Under these circumstances, the practice 
of making incisions into the diseased parts has 
been recommended. This plan was suggested 
many years ago by various writers on surgery, but 
first practised in this country by Mr. Copeland 
Hutchison. In his Practical Observations on 
Surgery, he recommends these incisions to be 
made about an inch and a half in length, from 
two to four inches apart, and varied" in number 
from four to eighteen, according to the extent of 
surface the disease is found to occupy. 

From these incisions fifteen to twenty ounces 
of blood will generally flow, reheving the lisnsion 
of the skin and at the same time giving exit to the 
pus. 

Mr. Lawrence (Med. Chir. Trans, vol. xiv.j re 
commends, in preference to these numerous inci 
sions, one or two long incisions carried through 
the middle of the inflamed part, in a direction j)a 



104 



ERYSIPELAS. 



rallcl to the long axis of the limb. " These inci- 
.^ions," he s;iys, " are followed very quickly, and 
sometimes almost instantaneously, by relief and 
cessation of the pain and tension ; and the allevia- 
tion of the local' suffering is accompanied by a cor- 
responding interruption of the inflammation, whe- 
ther it be in the stage of effusion, or in the more 
advanced period of suppuration and sloughing. 

"The treatment by incisions," he adds, "is 
suited to various stages of the complaint ; but it is 
employed to the greatest advantage at the begin- 
ning, since it prevents the further extension of 
inflammation, and the occurrence of suppuration 
and sloughing. At a more advanced period, the 
incisions limit the extent of suppuration and gan- 
grene, and at a still later time they afford the rea- 
diest outlet for matter and sloughs, and facilitate 
the commencement and progress of granulation 
and cicatrization." 

Mr. Lawrence does not advise incisions in ery- 
sipelas generally, but confines their employment 
to cases of the phlegmonous kind. This treat- 
ment, therefore, is more applicable to erysipelas 
of th« limbs than to the disease when it occurs 
either on the face and scalp, or on the trunk. 

After the incisions, warm fomentations should 
be applied till the bleeding has ceased ; the part 
should then be enveloped in a warm bread poul- 
tice. If the surface of the wound do not discharge 
freely, it should be dressed, under the poultice, 
with lint thickly spread with resinous or some 
other stimulating ointment. When suppuration 
is established, the matter finds a free discharge at 
the incision, large portions of cellular membrane 
are thrown off; and when this process is finished, 
pressure by a bandage is very useful in promoting 
the healing process. 

Though the bleeding, which takes place from 
the incisions, is generally serviceable in arresting 
the inflammatory process, it should not be checked 
so long as the pulse is unailected. The following 
passage from Mr. Lawrence's paper contains a 
valuable practical caution. " The great extent to 
w^hich the hemorrhage may proceed, renders it ne- 
cessary that we should act very cautiously, espe- 
cially in elderly persons, or in those whose strength 
is already impaired by the disease or previous 
treatment. The patient should be closely watched 
in such cases until the bleeding has ceased. 
Should it become necessary to stop the further 
loss of blood, this may be readily accomplished by 
tying any bleeding vessels, or placing the limb in 
an elevated position, or by pressure." 

It will be necessary in most instances to allow 
nutritious diet, and sometimes a little wine, to sup- 
port the powers under the process of suppuration 
and granulation. We have occasionally found it 
necessary to give wine, and even brandy, imme- 
diately after the incisions, when the patient has 
been exhausted by the hemorrhage ; but stimu- 
lants should be withdrawn after the powers have 
been restored. 

Further experience has confirmed the efficacy 
of this mode of treatment in cases of phlegmonous 
erysipelas, and, were testimony in support of the 
practice required, several instances which have 
iieen treated by incisions under the directions of 
»'ie writer of this article might be adduced. 

[r. some cases of erysipelas the accompanying 



fever is attended with symptoms of gastric irrita- 
tion ; the patient feels hot and flushed ; the tongue 
is red at the point and margin, the body of it be- 
inir coated with yellow moist fur ; there is a bitter 
taste in the mouth, often accompanied with vomit- 
ing of bilious fluid, or diarrhoea. 

If the pulse be full, and the general aspect of 
the symptoms denote acute fever, venesection and 
leeches to the epigastrium will, in general, quiet 
the gastric irritation, and relieve at the same time 
the local inflammation. 

3. In the oedematous form of erysipelas the local 
disease is certainly inflammatory ; but the consti- 
tutional excitement is seldom such as to warrant 
those depleting measures which are necessary in 
the more acute forms. Mild aperients, confine- 
ment to the horizontal posture, warm fomentations 
to the affected parts, and a restricted regimen, 
comprise all that is in general necessary in the 
treatment of oedematous erysipelas in its early 
stage. If the skin of the affected parts feci hot 
and painful, the application of leeches will be 
serviceable. Towards the decline of the disease, 
tonics, especially the sulphate of quinine, with a 
mild nutritious diet, will be useful. 

When erysipelas terminates in gangrene, bark, 
wine, and opium, with the occasional exhibition 
of mild aperients, are to be exhibited according to 
circumstances. 

4. In infantile erysipelas, the child's strength 
should be supported by means of a good nurse. 
If the milk of the mother be not sufficient, a wet- 
nurse must be procured, and cordials, such as 
white wine-whe}', small doses of quinine, and 
sometimes of ammonia, administered. 

F). The tendency of erysipelas to become erratic, 
or to rnigrate from one part of the surface to ano- 
ther, has been pointed out. We have also alluded 
to cases in which the inflammation, after suddenly 
leaving the skin, has been followed by inflamma- 
tion of some internal part. When this happens, 
the organ which has become diseased is to be 
treated on the same principles as when this inflam- 
mation occurs from other causes, while sinajiisms 
are applied to those parts of the skin from which 
the erysipelas has receded. It is therefore neces- 
sary, in all cases of erratic erysipelas, to watch 
the condition of the internal organs, and to treat 
with promptitude and decision the symptoms of 
internal inflammation on their first approach, 
always, however, keeping in view the general 
powers of the patient. 

6. When erysipelas supervenes on convalescence 
from other diseases, the treatment must be regu- 
lated according to the circumstances of the case. 
When it attacks convalescents from fever, it always 
retards, if it do not render the recovery doubtful. 
We have seen great benefit in such cases from 
abstracting blood on the very first appearance of 
the redness, by making numerous punctures with 
the lancet, and promoting the bleeding by warm 
fomentations. In several instances, this practice 
has at once put a stop to the disease. When it 
has proceeded after this local bleeding, a cooling 
plan of treatment with moderate support in cases 
of great debility, should be prescribed. In elderly 
persons stimulants, such as sulphate of quinine, 
ammonia, with wine and cordials, are often ne- 
cessary. 



ERYSIPELAS — ERYTHEMA. 



105 



Some continental surgeons have recommended 
the application of vesicants and escharotics as 
local remedies in erysipelas. Dupuytrcn employs 
blisters to the affected portions of skin in the se- 
cond stage of phlegmonous erysipelas. M. Larrey 
reports favourably of the edicacy of slight cauteri- 
zation of the surface in traumatic erysipelas. 

Mr. Higginbottom, of Nottingham, more re- 
cently, has recommended the application of nitrate 
of silver, with the view of arresting the spreading 
of erysipelatous inflammation. He conceives that 
the influence of this remedy (as an external ap- 
plication) is not confined to the textures consti- 
tuting the skin, but that it extends to the cellular 
substance, and even to the parts more deeply 
seated. This remedy is not to supersede active 
treatment when necessary. It is to be applied in 
the following manner. The part is to be first 
washed with soap and water, to remove any oily 
substance from the skin, and afterwards wiped 
dry ; the inflamed and surrounding skin is to be 
then moistened, taking care that not only every 
part of the inflamed skin be touched, but the sur- 
rounding healthy skin, to the extent of an inch or 
more beyond it. The nitrate of silver is to be 
passed over these surfaces once, twice, thrice, in 
common cases, and more frequently if rapid vesi- 
cation be required. After the application, the part 
is to be exposed to the air to dry, and is to be kept 
cool. Mr. Higginbottom has given, in his work, 
several cases illustrative of the efficacy of this plan 
of treatment. (See an Essay on the Use of Nitrate 
of Silver in the Cure of Inflammation, Wounds, 
and Ulcers, by John Higginbottom.) 

Compression by a well applied bandage has 
been employed in the later stages of erysipelas. 
From what we have witnessed, we are by no 
means inclined to advise this mode of treatment. 
If inflammation of the skin and cellular tissue still 
remain, pressure must prove most injurious ; and 
if there be infiltration of pus in the cellular tissue, 
it can be of no avail. We have seen more than 
one case of erysipelas, in which gangrene was in- 
duced within twelve hours after a bandage was 
applied. The only form in which it can be at all 
admissible, is in the suppurative stage of phleg- 
monous erysipelas, as already recommended, and 
in the chronic stage of oedematous erysipelas, after 
the inflammation has disappeared from the skin, 
when the limb continues enlarged from (Edematous 
effusion into the cellular tissue. 

[Mr. Davies (^Practical Remarks on the Use of 
Iodine locally applied, Amer. Lib. edit. 1839-40) 
has recommended in the same cases the tincture 
of iodine diluted with two parts of alcohol to one 
of the tincture, and applied over the affected parts 
by means of a camel's-hair pencil. It seems to act 
like the nitrate of silver, forming a coating over 
the inflamed surface, and thus protecting it from 
the air, whilst, at the same time, it acts as an 
excitant to the over-dilated capillaries. In local 
erysipelas, the writer has often found it markedly 
advantageous ; and M. Velpeau (Braithwaite's 
Retrospect, July to Dec. 1842, p. 117, Lond. 
1843) has observed a solution of sulphate of iron 
in the proportion of an ounce to a pint of water, 
or an ointment of the same, in the proportion of a 
drachm to an ounce of lard of great service. 

A few years ago, the application of mercurial 

Vol. II 14 



ointment to the inflamed parts was brought for- 
ward with high encomiums, and was extensively 
used, (T. Nunneley, Treatise, Sfc. on Erysipelas, 
Amer. edit. p. 214, Philad. 1844); but the writer 
has not been able to notice any better effects from 
it than from greasy applications in general, whilst 
it has at times acted as an irritant when the latter 
might have not. 

Except, however, in local erysipelas, the writer 
is not in the habit of employing topical remedies 
to the inflamed part. He has found decided benefit 
from carefully excluding the air from it by cover- 
ing it with carded cotton, as in cases of burns and 
scalds. The great object would seem to be, to 
remove the constitutional affection of which the 
exanthem is only a functional expression, like the 
eruption of small-pox, measles, or scarlatina. It 
must be borne in mind, that this is largely neuro- 
pathic, and that great benefit often results from 
agents that would be justly esteemed questionable 
in ordinary inflammation. A recent writer of 
authority. Dr. Robert Williams, (^Elements of 
Medicine,) states, that the mode in which he is in 
the habit of treating " idiopathic erysipelas, what- 
ever may be the part affected, or with whatever 
symptoms it may be accompanied," is as follows : 
the patient is put on milk diet ; the bowels are 
gently opened, and from four to six ounces of 
port-wine, together with sago, are allowed daily. 
" This mode of treatment," he says, " it is seldom 
necessary to vary throughout the whole course of 
the disease ; for the delirium, if present, is gener- 
ally tranquillized ; if absent, prevented ; the tongue 
more rarely becomes brown, or only continues so 
for a few hours ; while the local disease seldom 
passes into suppuration or gangrene. In a word, 
all the symptoms are mitigated, and the course of 
the disease shortened. I have pursued this sys- 
tem," he adds, " for several years, and I hardly 
remember a case in which it has not been success- 
ful." Dr. Williams does not limit the quantity 
of wine to that above stated. In more severe 
cases, where the local affection continues to ex- 
tend, and the delirium to augment, he increases 
the wine to eight ounces, and adds quinia to it.] 

A. TWEEDIE. 

ERYTHEMA, (from the Greek lfi6n)>a, red- 
ness,) is one of those nosological terms which has 
been made use of in various significations by dif- 
ferent writers, and its application is, even at the 
present moment, in some degree vague and arbi- 
trary. 

Hippocrates used it in the general sense of a 
morbid redness of the skin, of any kind, for which, 
at a later period, Celsus, and, after him, Galen, 
substituted the term erysipelas ; and hence, per- 
haps, arose a good part of the confusion which we 
meet with in the subsequent application of the 
terms. In the system of Sauvages, erythema is 
synonymous whh idiopathic erysipelas. Cullen 
says, " when the disease is an affection of the skin 
alone, and very little of the whole system, or when 
the affection of the system is only symptomatica) 
of the external inflammation," it is erythema , 
" but when the external inflammation is an exan 
thema and symptomatical of an aflection of tho 
whole system," he calls it erysipelas . and with 



1JD6 



ERYTHEMA. 



this Mason Good nearly coincideE, applying the 
former appellation to a local cutaneous inflamma- 
tion tending to vesication, and the latter to an 
idiopathic fever producing an crythematic efflores- 
cence. Callisen implies by erythema the lowest 
degree of erysipelas; and with Rostan, in lilie 
manner, it means this same disease in its simplest 
form. J. P. Fratik, however, employs it in a very 
different signification, confining its use to a morbid 
redness of the skin, of a chronic nature ; but in 
this he is peculiar ; at least it is not the sense in 
which it has been employed by the majority of his 
countrymen. In Germany, indeed, it seems for 
the most part to have been confounded, along 
with some other cutaneous affections, under the 
common head of erysipelas, (Rose, Rothlaiif, &c.) 
till Rust (Magazin fiir d. ges. heilkunde. b. viii.) 
restrained the use of the term erysipelas to that 
species of cutaneous efflorescence which is accom- 
panied with fever, and dependent on disorders of 
the digestive organs, and drew a line of distinction 
between tliis and a similar-looking inflammation 
of the skin, originating in some local irritation (as 
excess of cold or heat, chemical agents, or slight 
wounds,) or in a morbid state of some of the sub- 
jacent structures, (as inflammation of membranous 
expansions, metastatic depositions into the cellular 
membrane, periosteum, or glands, &c.) This 
latter affection, whether idiopathic or symptomatic. 
Rust has distinguished by the appellation pseudo- 
erysipelas, and it evidently coincides very nearly 
with the " erythematic inflammation" of many 
medical and surgical writers in our own coun- 
try. 

In Willan's arrangement, erythema signifies " a 
nearly continuous redness of some portion of the 
skin attended with disorder of the constitution, 
but not contagious ;" to which Bateman adds, " it 
differs from erysipelas inasmuch as it is a mere 
rash or efflorescence, and is not accompanied by 
any svs'elling, vesication, or regular fever." 

Rayer defines it to be a superficial inflammation 
of the skin, characterized by morbid redness and 
heat, and the absence for the most part of papula;, 
vesicles, and pustules ; and in his latest work he 
says it is the first stage of a number of cutaneous 
affections, but when permanent it constitutes in 
itself a distinct disease ; and Biilard adds, that as 
it often ushers in other cutaneous diseases, so it 
occasionally also forms their termination. Rayer 
thinks Bateman has fallen into an error in attri- 
buting such formidable symptoms as he does to 
some of his varieties of erythema, as they ought 
to be referred, not to this trivial inflammation, 
which is in itself productive of no danger, but to 
the coexistence of internal affections, chiefly in- 
flammations of the mucous membrane of the 
stomach and intestines. These, which not unfre- 
quenlly complicate it, have, he asserts, been over- 
looked by our English pathologist. The accusa- 
tion, however, does not appear to us altogether 
well founded, as Bateman sets out by saying that 
erythema, like roseola, is commonly only a second- 
ary affection — a mere symptom, though often the 
most prominent one, of dyspepsia, disorder of the 
Dowels, and other internal derangements. 

Having thus passed in review most of the sig- 
nifications which have at various times been at- 
i»ched to tne term erythema, we have only to add. 



that the sense into which it has gradually been 
subsiding in these countries, and in winch we 
mean to employ it here, is that of a superficial in- 
flammation of the skin, which is red and occa- 
sionally hot and itchy, but without vesication or 
obvious swelling. We shall adopt the primary 
subdivisions of this affection which have been em- 
ployed by Rayer, viz. into idiopathic and symp- 
tomatic, as at once more comprehensive and more 
practical than those of Willan and Bateman, all 
of whose six varieties are easily reducible to the 
second of the above heads. In reference to treat- 
ment, the division into acute and chronic is also 
most important, and should never be lost sight of 
in the management of an individual case. 

Idiopathic or Local Ehtthema is often 
traceable to some obvious cause of topical irrita- 
tion, as friction or pressure, extremities of heat or 
cold, the stings of insects, chemical irritants, dis- 
tension of the integuments, or, finally, to the in- 
flammation excited on the surface of the neigh- 
bouring skin by the existence of some papular, 
vesicular, or pustular eruption, or by wounds, 
ulcers, &c. 

Of erythema induced by friction (intertrigo), 
we have a familiar example in that chafing of the 
skin which occurs especially in fat persons who 
are inattentive to personal cleanliness. The parts 
where it usually takes place are about the axilla, 
groins, inner and upper part of the thighs, and in 
the cleft of the nates. It depends on the attrition 
of the contiguous surfaces in these situations, 
where the skin is of a delicate texture, and where 
there is considerable moisture or sebaceous secre- 
tion, and much movement of the parts. It very 
often makes its appearance behind the ears of in- 
fants, as well as in the folds of the neck, about 
the pudenda, back of the knees, &c. The irritated 
parts secrete in abundance a pale viscid fluid, even 
before they are.excoriated or ulcerated, which con- 
cretes into scabs, and seems to be a modification 
of the secretion of the sebaceous follicles which 
are very much developed in infants at birth. The 
itching and irritation of intertrigo in young chil- 
dren is occasionally so considerable as to interfere 
materially with their rest. 

Where the redness is intense, and confined to 
the circumference of the anus, and a considerable 
diarrhoea coexists, we may generally consider it as 
the result of this aflection, and produced either by 
an extension of the inflammation of the mucous 
membrane of the rectum to the adjacent skin, or 
by the repeated application of discharges of an 
unnatural and stimulating quality. A similar 
irritation and redness occasionally occurs in a 
chronic form about the verge of the rectum in 
adults. It is accompanied with distressing itch- 
ing, and seems for the most part to be connected 
with deranged action of the stomach and bowels. 
As it is often accompanied by a copious secretion, 
which concretes into scales, it is probably more 
closely allied to eczema than to the subject of the 
present article, though in many ca.ses it is very 
doubtful to which it should be referred. (See 
Eczema.) When the redness about the anus 



and genitals of infants is of 



a somewhat coppery 



or hvid hue, and resists frequent ablutions and the 
other simple means usually employed by nurses, 
we must investigate the case accuratelV, and as- 



ERYTHEMA. 



107 



certain whether the parents or nurse labour under 
the suspicion of syphilis in any of its forms. 

Erythema often makes its appearance on the 
cheeks of infants during the period of dentition, 
and in the neighbourhood of the umbilicus while 
the cord is sloughing off. 

Of the erythematous redness induced by pres- 
sure we have familiar examples in the effects of 
a tight shoe, — of a long ride on one unaccustomed 
to it, — of protracted confinement to bed and con- 
stant lying on the same points of the body. (E. 
Paratrima of Sauvages.) 

Of that caused by extremes of temperature we 
have instances in the redness of chilblains, and 
of slight burns and scalds. 

The chemical irritants capable of inducing it 
are numberless. Ammoniacal and other stimulat- 
ing liniments, blisters, pitch-plasters, sinapisms, 
turpentine, washes containing lead, and even the 
long-continued application of linseed poultices, 
occasionally produce this eruption in very irrita- 
ble skins. In many instances, however, the pre- 
sence of vesicles may be detected, and such cases 
will fall under the head of eczema. The long-con- 
tinued or repeated application of the urine which 
occurs in certain diseases of the bladder and ure- 
thra ; of the faeces in dysentery ; or of both, in 
young infants who are not kept with a sufficient 
attention to cleanliness ; as also the contact of 
gonorrhoeal, leucorrhoeal, and other morbid dis- 
charges, are frequent causes of this affection of 
the skin : even the long retention of the natural 
secretion of the sebaceous follicles around the co- 
rona glandis, by becoming rancid and acquiring 
irritating qualities, may give rise to this inflamma- 
tion in the prepuce. 

We have examples of the influence of disten- 
sion of the skin in producing erythema, in the 
redness which sometimes manifests itself over the 
surface of the most prominent part of tumours, 
aneurismal and others, of rapid growth ; and to 
this distension may, perhaps, be referred in part 
the blush of redness which indicates to the sur- 
geon the existence of deep-seated matter, the in- 
flammation of tendinous fascia;, periosteum, &c. ; 
though, doubtless, much of this depends on sym- 
pathy of the vessels of the skin with those of the 
aubjacent parts. The red lines which occur over 
the track of inflamed absorbents and veins are of 
a similar nature, as well as the diffused blush over 
a joint sullering from acute rheumatism or gout. 
To distension, too, we must attribute the superfi- 
cial inflammation which so often attacks dropsical 
parts, especially the lower extremities and scrotum, 
the skin being put greatly on the stretch by the 
serous effusion into the cellular membrane. As 
the anasarca declines, this usually terminates in 
extensive desquamation of the cuticle ; but in less 
favourable cases, especially in elderly and intem- 
perate people, whose constitutions are exhausted 
by violent or long-continued diseases of the chest 
or abdomen, the efflorescence often assumes a 
dark red or livid hue, and gangrenous ulcers en- 
sue ; a termination which is sometimes accelerated 
by the injudicious use of scarification, or by an 
improper mode of performing this operation. In 
those cases where it is desirable to drain off the 
water in anasarca, punctures with a lancet are, as 
Mr. Pott long since pointed out, much preferable 



to incisions, as they are equally effectual in giving 
passage to the fluid, and are much less likely to 
inflame or become gangrenous, — a result which 
there is so much reason to dread in dropsical hab- 
its. Pott gives three cases in which the whole 
integuments of the penis and scrotum, which 
were greatly distended by serous infiltration, 
sloughed off, in consequence of incisions instead 
of punctures having been made into the swollen 
parts. M. Fouquier finds that gangrenous in- 
flammation is least apt to ensue when the punc- 
tures have been made deep, by plunging the lan- 
cet quite through the skin and freely into the cel- 
lular membrane. The greater safety of this pro- 
ceeding may, perhaps, be ascribed to its being 
more effectual in draining off the water, and thus 
more rapidly relaxing the integuments, and re- 
lieving that state of tension which predisposes to 
inflammatory action. It has lately been recom- 
mended by Dr. Marsh to perforate the anasarcous 
swelling in several points with a cataract needle, 
after which the serum will continue for many days 
to exude abundantly, and from the smallness of 
the wound inflicted the risk of inflammation will 
be much diminished. 

Of the erythematous redness induced by the 
irritation of vesicular, papular, and pustular erup- 
tions, we see frequent examples. Thus the are- 
ola of the vaccine vesicle sometimes extends to a 
considerable distance, so as to cover the greater 
part of the arm, and in some rare cases even 
the breast, back, neck, and face. When so exten- 
sive, it has usually been described as a species of 
erysipelas, and is accompanied with a considera- 
ble degree of stiffness and difficulty in the motion 
of the parts affected, with some feverishness and 
occasional enlargement of the axillary glands. It 
has been known to turn livid, and has then been 
sometimes attended with fatal debility. Bateman, 
we are aware, has classed this affection under 
roseola. We are not desirous of displacing it, 
but rest content with pointing oul its affinity to 
the genus under consideration, to which by its 
origin, apparently from the local irritation of the 
skin, and by its spreading in a continuous man- 
ner, it seems to be very closely allied. Indeed, 
no very accurate line of distinction is drawn by 
Bateman between roseola and erythema; and 
Plumbe has treated of them both together as mere 
symptoms of internal or constitutional disorder. 
According to Rayer the inflammation of erythe- 
ma is of a deeper red and more pronounced char- 
acter than that of roseola, and sometimes extends 
to the cellular membrane, or becomes chronic, 
neither of which is ever the case in the latter. 
The spots are moreover generally larger, but less 
numerous than in roseola, in which last they often 
occur simultaneously in almost every part of the 
body. After all, we think that these affections 
graduate insensibly into one another, and that in- 
numerable cases present themselves in practice 
which are equally referable to either. 

The extensive redness which accompanies some 
species of strophulus and lichen exemplifies the 
connection of erythema with a papular disease. 

One species of acne (gutta rosea) is usually 
complicated with a diffuse redness, which is of so 
striking a character, as to have led Frank, though 
incorrectly, to class this pup'nlo-tubercular affer- 



108 



ERYTHEMA. 



tion under the head of erythema. The affected 
parts of the face, in addition to the characteristic 
suppurating tubercles, present a shining redness, 
and occasionally an irregular granulated surface, 
generally commencing at the point of the nose 
and gradually spreading to the neighbouring part of 
the cheeks, and frequently attacking also the fore- 
head and chin. After some years the skin assumes 
a rough and thickened appearance, and is tra- 
versed by a net-work of enlarged veins. It seems 
often to depend on derangement of the digestive 
organs, and a peculiar irritability of the stomach 
in particular ; but these are rarely so well marked 
or so clearly characterized as to enable us accu- 
rately to discriminate, or to justify us in attempt- 
ing to separate, in our classification, the symp- 
tomatic from the strictly local examples of this 
aiTcction. The vividness of the colour of the erup- 
tion is greatly increased immediately after making 
use of any warm or stimulant food or drink, sit- 
ting opposite a hot fire, long-continued exposure 
of the face to the sun's rays, violent exercise, 
much stooping, reading or writing soon after 
meals, straining the eyes on minute objects, de- 
rangement of the stomach, constipation, or in fine, 
any of those causes which produce a temporary 
determination of blood to the head. In young 
persons who inherit this complaint, it appears in 
the form of red patches of an irregular shape on 
the face, from which scurfy exfoliations of cuticle 
take place from time to time, but the tubercles do 
not usually appear till a later period. Unless, 
however, there is a very decided hereditary pre- 
disposition to it, or habitual intemperance, it does 
not usually show itself till middle life. As the 
person advances in age, the nose becomes swollen 
and of a fiery red, the nostrils dilated, and the 
skin assumes a lobular or tubcrculated aspect, 
with considerable development of the sebaceous 
follicles which abound in this part. In a case in 
St. Bartholomew's Hospital in which the jiose had 
from this cause a very unreasonable and incon- 
venient magnitude, we witnessed the removal of a 
portion of it by the knife, with considerable im- 
provement to the physiognomy. 

According to Frank's definition of erythema, 
which seems to be entirely drawn from the affec- 
tion which we have just described, it is a superfi- 
cial, habitually recurring, or permanent chronic 
redness of the skin, which grows pale on pres- 
sure, and is attended with a sense of itching, heat, 
and tension, with little real tumefaction or ten- 
dency to suppuration. He adds that it may be 
either smooth or studded with tubercles, and is 
very frequently accompanied with a furfuraceous 
exfoliation of the cuticle, and he points out the 
legs and face as its most frequent situation. As 
long as it is not repelled from the surface, he con- 
siders it usually unimportant. The skin becomes 
thickened, hardened, and deformed by its frequent 
recurrence. With many it continues throughout 
life, and with others returns almost periodically, 
without any evident lesion of other functions of 
the body. On desquamating, it leaves the skin in 
a slate of increased sensibility, and prone to sub- 
sequent attacks. Its causes, he conceives, differ 
little from those of erysipelas, save in degree and 
permanence. The passionate, intemperate, and 
feeble are most lia'ile to it, and suppression of the 



menses, of hemorrhoids, or of an habitual perspi- 
ration in the feet or axillae occasionally give rise 

to it. 

In the case of irritable wounds, leech-bites, ul- 
cers, issues, setons, and blisters long kept open, 
the inflammation frequently extends from theui to 
the surrounding skin, and manilests itself by a 
blush of redness which disappears on pressure. 
This, when accompanied neither by obvious tu- 
mefaction nor tendency to vesication, we should 
class under the head of erythematous inflamma- 
tion, rather than under the formidable name of 
erysipelas, which is frequently bestowed upon it 
In a practical point of view, it is desirable that an 
affection of so slight a nature and requiring so 
little treatment should have a distinct and appro- 
priate appellation. 

Into that species of erythematous efflorescence 
accompanied with a boggy intumescence of the 
subjacent cellular membrane, which occasionally 
supervenes upon wounds received in dissection, 
we do not mean to enter here, as the dangerous 
afiection of which it is but one out of many more 
formidable symptoms, will be treated of in another 
place. 

The disease which has been described by some 
writer under the name of erythema mercuriale is 
a vesicular disease, and will therefore be found 
under the head of Eczema. 

The treatment of idiopathic erythema is gene- 
rally simple. That arising from the chafing of 
contiguous surfaces may be prevented, for the 
most part, by assiduous attention to cleanliness, 
frequent washing with cold water, and the occa- 
sional use of the tepid bath. If excoriation has 
been already induced, emollient applications, as 
decoction of bran or of marsh-mallows, or a sim- 
ple ointment, will generally suffice for its cure. 
In some individuals, however, ointments and 
greasy applications generally prove irritating, caus- 
ing an increase of inflammation, and promoting 
suppuration of the denuded surface. Wiien the 
part is very painful and considerably inflamed, 
a solution of the nitrate of silver affords one of 
the most healing, and after the momentary suffer- 
ing immediately ensuing upon its use is over, one 
of the most soothing applications. Fat persons 
who have been in a state of torture after a long 
walk, or a hard day's shooting, have often found 
instant relief from this remedy. Keeping the part 
constantly wet with Goulard's lotion is also very 
effectual. 

The intertrigo occurring behind the ears in in- 
fants generally requires little more than scrupulous 
attention to cleanliness, and the interposition of a 
singed rag to absorb moisture. Such sores as 
form in this situation, if kept constantly moistened 
with a weak solution of the acetate of lead, will 
usually heal rapidly. Most authors, however, 
caution us against drying them up, dreading from 
such imprudence the occurrence of ophthalmiae, 
inflammations of the brain, stomach, or intestines, 
or some other serious complaint ; but by taking 
care to induce a somewhat freer state of the bow- 
els whilst healing these sores, and by slightly re- 
ducing the quantity of the child's food, we shall 
probably in most instances obviate all dau'-ers 
from this source. In all cases, however we should 
endeavour, by attention to cleanliness, to prevent 



ERYTHEMA. 



109 



the affection ever going so far that either its exis- 
tence should be productive of much inconvenience, 
or its removal of nmch risk. The advocates of 
the prophylactic virtues of such sores should be 
made aware that they often become in themselves, 
from their painfulness and foetor, and the swelling 
of the cervical glands which they induce, very 
troublesome ailments; and that they have even, 
in some cases, been known to prove fatal by the 
extension of the inflammation to the internal ear, 
and to the brain. The sores, too, occasionally 
become livid and gangrenous, and the child sinks 
even before the sloughs have separated — a termi- 
nation which has been mentioned by Burns, who 
in such cases dwells on the necessity of directing 
all our efforts to supporting the strength, regulat- 
ing the bowels, and counteracting the tendency 
to mortillcation by the application of camphorated 
spirits, the fermenting poultice, &c. 

Where intertrigo makes its appearance in the 
folds of the neck, about the arm-pits, groins, or 
hams, daity bathing, and the occasional exposure 
of the parts to the air, together with sprinkling 
them with some unirritating absorbent powder, 
as tutty, levigated chalk or starch, is all that is 
usually necessary. Chausier and Plenck caution 
us against the use of cerusse (carbonate of lead), 
as being sometimes productive of pains in the ab- 
domen, paralysis of the hands, and all the other 
symptoms of lead colic. Yet it is still not un- 
frequently employed in this country, and we are 
surprised to find it recommended by J. P. Frank, 
Mason Good, and Burns, as one of the best pre- 
parations for dusting excoriations in children. A 
lotion containing the sulphate of zinc, and a weak 
spirituous wash, are often useful applications. 

The erythematous inflammation induced by 
pressure will generally cease on the removal of 
the cause. Where it occurs from lying long on 
the same parts, as often takes place in tedious 
fevers, in phthisis, and in those who are bed-rid- 
den from other chronic disease, a change of pos- 
ture, if possible, or the judicious application of 
pillows, so as to take the weight of the body off 
the prominent and inflamed points, are obvious 
modes of relief. Protecting the skin by chamois 
leather, soap-plaster, gold-beater's leaf, or white 
of egg coagulated by alcohol, are expedients to 
which we are obliged to have recourse when the 
posture cannot be changed. In low fevers the 
cutaneous vessels partake of the general debility 
of the system, and like other weak and irritable 
parts are readily excited to inflammatory action 
by the stimulus of pressure. Camphorated and 
spirituous washes seem, when early applied, to 
have considerable effect in hardening the skin, 
supporting the tone of its vessels, and enabling 
them to resist the influence of the above cause. 

The treatment of the erythematous inflamma- 
tion induced by extremes of temperature is to be 
found in all systematic surgical works. 

The redness ensuing upon the sting of an in- 
sect is generally so transitory and trifling as not 
to require any medical aid. After the extraction 
of the sting, the application of olive oil with 
opium and ammonia are amongst the most effec- 
tual means of giving relief. The efliicacy of am- 
monia is, probably, in some degree attributable 
to its chemical action, as the irritating fluid intro- 



duced by the sting, is generally, as Tiedemann 
has observed, of an acid quality. A great share 
of its influence is also, no doubt, ascrihable to its 
changing the mode of the sensibility in the irrita- 
ted parts. 

That species of erythematous efflorescence 
which is brought on by the application of chemi- 
cal agents to the skin, usually ceases speedily 
after their application has been omitted ; and its 
disappearance may be accelerated by emollients, 
fomentations, and other measures, which at once 
tend to remove all remains of the irritating sub- 
stance, and to relax and soothe the excited skin. 
Where the irritating matter is of a resinous nature, 
oily applications will greatly facilitate its removal. 

When the contact of urine and fasces is the 
source of the evil, frequent changes of linen are 
indispensable, and every effort should be made to 
keep the parts clean and dry. The detail of the 
expedients which have been devised for the ful- 
filment of this object is to be found in such works 
as treat of diseases and injuries of the bladder, 
urethra, &c. 

When erythema results from the distension 
of the skin by tumours of rapid growth, relaxant 
applications under some circumstances, and the 
application of leeches and cold under others, are 
called for ; but as such cases usually fall under 
the care of the surcreon, we shall not dwell on 
them here. Where this inflammation is induced 
by anasarcous distension, a horizontal posture is 
very important, and frequent fomentations, and 
keeping the limbs enveloped nighl and day in lint 
moistened with water, and the whole wrapped up 
in oiled silk, so as to prevent too rapid evapora- 
tion, are measures which tend notably to diminish 
tension by keeping the skin in a relaxed and per- 
spirable state, and which have likewise great 
influence in subduing local inflammation. When 
the inflamed surface assumes somewhat of a livid 
or brownish hue, and threatens gangrene, the use 
of dilute spirituous and camphorated fomentations 
is the common practice, though the propriety of 
it is not universally acknowledged. Those who 
look upon inflammation as the source of all the 
danger, prefer soothing applications throughout. 
Whilst using these local measures, we must at 
the same time endeavour to promote the absorp- 
tion of the effused fluid, support the strength, and 
combat disease of the heart, lungs, serous or mu- 
cous membranes, which so often coexists in these 
cases, and as being the principal cause of all the 
other symptoms, demands our chief attention. 

When the irritation of some papular, vesicular, 
or pustular disease seems to be the exciting cause 
of erythema, the latter may generally be disre- 
garded, provided we take the proper steps for re- 
lieving the primary affection, and these will pro- 
bably for the most part be found in the due em- 
ployment of soothing or antiphlogistic measures. 
In that species which so often complicates acne, 
where it is constitutional, a cure need hardly ever 
be expected, as it seems to depend in some de- 
gree on a varicose state of the minute veins. Cold 
evaporating and slightly astringent lotions, •.with 
moderate but long-continued pressure, are almost 
the only measures which afford permanent benefit 
in varicose affections of the smaller veins in other 
parts of the body ; but they are, if not whollv ir 



no 



applicable in this situation, at least too inconve- 
nient to give them any chance of being steadily 
and long enough employed. Very great tempe- 
rance, regular exercise, and avoidance of all those 



ERYTHEMA. 

'^Symptomatic Ehtthema is associated with 
many inflammatory affections, especially those of 
the mucous membrane of the stomach and mtes- 
tines; and the symptoms which have been by 



a:sesXh;rhave' pointed out as tending to some attributed to the -^ - 
exasperate this affection, should be strongly en- '•"<'"- - --" '^s 'tselt. dependent o 
joined. Where the scurfiness is considerable, 
some mild ointment is useful in removing or con- 
cealing it. If the affection be purely local, slightly 
astringent lotions of lead or zinc, with a small 
portion of alcohol or vinegar, may be tried, or oint- 
ments of a similar nature ; but they will too often 
prove nugatory in their effects. The popular use 
of vs'ater-cresses and other raw vegetable matter, 
under the name of antiscorbutics, is highly irra- 
tional. A somewhat tonic regimen, and the use 
of flesh meat in preference to an exclusively vege- 
table diet, are proper. We have lately met with 
a striking exemplification of this in the case of a 
distinguished artist, in whom this affection, in- 
duced by the habitual stooping which the exer- 
cise of his profession required, was greatly and 
suddenly aggravated by a strict adherence to a 
vegetable diet, and again diminished considerably 
on his -returning to the free use of flesh meat. 
The distension and acidity of stomach which an 
excess of vegetable food often induces, assist us in 
explaining its injurious effects in such cases. 
W'here the eruption depends upon some chronic 
derangement of the digestive organs and an irrita- 
ble state of the stomach, little can be expected 
from topical applications. Stimulants (and most 
of the empirical lotions for this affection contain 
corrosive sublimate, and are of this nature,) are 
usually injurious, and to remove this efflorescence 
by astringents, where possible, might do much 
mischief, by exasperating the internal disorders 
from which they spring. Alkalies internally seem 
sometimes useful, which is attributable, probably, 
to their antacid power, and their directly soothing 
effects on the mucous membrane. The regula- 
tion of the functions of the stomach, bowels, and 
liver, with a careful attention to the diet, are the 
most important points in endeavouring to prevent 
its increase. 

The redness of the skin which is occasionally 
induced by inflamed ulcers, leech-biles, painful 
issues, &c., in addition to such internal antiphlo- 
gistic means as the existing state of the system 
may appear to indicate, requires locally merely 
the application of a bread-and-water poultice, or 
of lint, moistened with cold water and enveloped, 
. as directed above, in oiled silk, to prevent its dry- 
ing rapidly by evaporation. The erythematic in- 
flammation succeeding to the use of leeches seems 
often to be induced, not so much by the irritation 
of the wounds they inflict, as by that excited in 
them by the subsequent application of Goulard 
and other astringent tonics. Where it is neces- 
sary to apply cold to a part immediately after 
leeches have fallen off, by confining ourselves 
simply to the use of cold water, in preference to 
these medicated lotions, we shall rarely have the 
mortification of seeing this cutaneous affection, 
which is often very annoying to the patient and 
his attendant, ensue; whilst, at the same time, the 
temperature may, by means of the coldness of the 



affection 
really, as well as itself, dependent on the state of 
the internal organs. The measly efflorescence so 
common in our continued fevers of some years, is 
a striking example of the sympathy of the cuta- 
neous system with the mucous membrane. In 
dysentery, too, exanthematous efflorescences occa- 
sionally occur, and sometimes, according to Cho- 
mel, form a salutary crisis to the disease. 

The erythema of Willan and Bateman, of 
which we have already given the definition, 
nearly coincides with Raycr's er}'thema sympto- 
maticum, and has been divided into six varieties. 
In some of these the eruption is more or less ele- 
vated at some period of the course, thus slightly 
approximating them to the papular and tubercular 
classes ; but these elevations are obscure and soon 
subside. W^illan has, however, availed himself 
of their temporary existence to form the ground- 
work of some of his subdivisions. 

1. Erythema fugax (maculffi volaticse) con- 
sists of evanescent red patches of an irregular 
figure, which appear successively on the breast, 
neck, arms, and face, in various febrile disorders, 
in bilious diarrhoea, in chronic affections of the 
primes viae, dyspepsia, hysteria, &c. The heat of 
the affected skin is increased, and the disappear- 
ance of the patches is not accompanied with any 
e\'ident desquamation. 

2. Erythema la>ve of Bateman coincides 
almost, if not altogether, with the species which 
we have already described as depending on drop- 
sical distension. He dwells on the usual coexist- 
ence of anasarca, on the smooth shining surface, 
its appearance chiefly on the lower extremities, 
and its termination in desquamation, and says it 
may occur either in sedentar}' young persons, in 
whom exercise, diuretics, and corroborants will 
contribute to shorten its duration, or also in elderly 
or anasarcous subjects, especially if intemperate, 
and is liable to terminate in gangrenous ulcers. 
The distended skin is often chequered with patclics 
of a dark red or purple hue. Horizontal posture, 
diuretics and bark, with weak spirituous lotions, 
are recommended by him. He adds, that it some- 
times occurs without oedema where the bowels 
have been much disordered, and occasionally is 
worse at the menstrual period. 

3. Erythema marginatum occurs chiefly in 
old people on the loins and extremities in the 
form of patches, which are in some places ob- 
scurely papulated, and are bounded on one side 
by a hard, elevated, tortuous, red border, but are 
not regularly defined on their open side. They 
have an uncertain duration, and are not productive 
of any irritation in the skin. They are connected 
with some internal disorder, and are usually an 
unfavourable symptom. 

4. Erythema papulativm consists of large, 
vivid, red, irregular patches, chiefly on the arms, 
neck, and breast, generally preceded for a day or 
two by obscure papute, which give a roughness 



,.-,-, . to the skin. The eruption, after continuin(r"nbout 

water and its gradual evaporation, be regulated a fortnight, becomes bluish esneciallv in h 
»aite as cffcctualh. tre of th^ natr-hpc .n-i „,„.!.._.,.. , :*. " - 



tre of the patches, and gradually declir 



cen- 
There 



ERYTHEMA — EUTROPHIC. 



Ill 



id occasionally, though not always, considerable 
constitutional disturbance, indicated by a small, 
freqncnt pulse, anorexia, and great depression, 
with severe pain and tenderness of the limbs. 
The treatment consists in light diet, diaphoretics, 
the mineral acids, and attention to the state of the 
bowels. 

5. Erythema tubvrciilatnm occurs, like 
the preceding, in large, irregular, red patches, but 
through these small tumours are dispersed, sub- 
siding in about a week, and leaving the erythema 
behind them, which, becoming livid, disappears in 
about a week more. It is usually ushered in by 
fever, and is accompanied with languor, irrita- 
bility, and restlessness, and is succeeded by hectic. 
It is so rare, that Bateman himself never saw it, 
and Dr. Willan, on whose authority he gives it, 
met with but three cases, and medicine seemed to 
have no effect either in alleviating them or in 
warding off' the subsequent hectic. 

6. Erytliema nodosum seems peculiar to 
females, and occurs chiefly about the shins. It is 
preceded by slight febrile symptoms, which cease 
on its appearance. It presents itself in the form 
of oval patches, with their long axis parallel to the 
shin bone. They rise slowly into hard and painful 
protuberances, which gradually subside within 
nine or ten days, their colour about the same time 
turning bluish. It is a mild affection, requiring 
usually only laxatives, mineral acids, and other 
tonics. We have known it, however, return fre- 
quently in the same individual, attended with 
considerable oedema, and after terminating in des- 
quamation, succeeded by severe pains in the limbs, 
which demanded the employment of pediluvia, 
bandages, &c. 

To these six varieties mentioned by Willan and 
Bateman, we give a seventh, general erythema, 
on the authority of Rayer, who says it has been 
overlooked by most writers on cutaneous diseases, 
or confounded by them with erysipelas. It con- 
sists in a superficial redness of the skin unequally 
distributed over various parts of the body, and 
occasionally differing but slightly from the natural 
colour of the integuments, and unaccompanied by 
swelling or vesications. It is attended with heat 
and dryness of the surface, and its duration rarely 
exceeds a week. The redness may be contiiiued 
or intermittent, or appear only momentarily, during 
the exacerbation of gastro-enteritic or other acute 
internal inflammations. It often disappears on 
the approach of death. In those who recover, 
desquamation and falling out of the hair one or 
two weeks after the disappearance of the eruption, 
often occur. 

This species, and, indeed, all cases where the 
erythema presents itself in an acute form, require 
antiphlogistic regimen, and occasionally venesec- 
tion, with cooling and emollient lotions, and the 
tepid bath. 

In the chronic varieties of erythema, Rayer 
recommends leeches to be applied round the 
affected parts, together with tepid and vapour 
baths, or the douche impregnated with sulphuret- 
ted hydrogen. Where the cutaneous inflamma- 
tion depends on some evident derangement in the 
stomach or intestines, the applicatjon of leeches in 
the neighbourhood of these organs may also be 
necessarv. W. B. Joy. 



[EUTROPHIC; from tv, "well," and rooir, 
"nourishment:" that which is capable of inducing 
improved nutrition. A term introduced by the 
writer into medical terminology, to include agents 
whose action is excited on the system of nutrition, 
without necessarily occasioning manifest increase 
in any of the secretions. In this wide sense, it is 
almost synonymous with alterative (q. v.) The 
term alterative has, however, been used most inde- 
finitely. Every remedial agent must, indeed, 
modify or alter, directly or indirectly, one or more 
of the functions; and, therefore, must be regarded 
as an alterative. Tonics induce this effect by the 
impression they make on the nervous system ; 
Direct etJtrophics, in the sense employed by 
the author, by modifying the fluid of the circula- 
tion, so that, when it permeates the intermediate 
system of vessels, it may impress them differently, 
and thus alter morbid actions that may be taking 
place in them. There are but two ways, perhaps, 
in which alteratives can exert their agency on the 
system : the one is through the new impression 
they make directly on the nerves ; the other, 
through the way of absorption. Tonics, it is pro- 
bable, act in the former mode ; eutrophics, — which 
occasion the absorption of solid parts of the body, 
— most substances, indeed, which impress new 
activity on the capillary system — generally in the 
latter. 

There are agents, however, which modify nutri- 
tion indirectly, — not by any change, which they 
effect in the fluid of the circulation, and which 
may, therefore, be called Ixdihect Euteopuics ; 
the various alterative agencies, for example, re- 
ferred to under another head. (See Altera- 
tives.) The influence of the nervous system as 
a modifier of nutritive action is strongly exem- 
plified, when powerful impressions are made upon 
it. Of this we have examples in the effect of the 
imagination, or of new impressions on the nerves, 
in discussing tumours of various kinds. Some of 
these growths are possessed of little vitality ; and 
if the nervous and vascular influence be detracted 
from them, they speedily die. This is the way in 
which charms remove warts. It is a common, 
popular superstition, that a dead man's hand, 
rubbed on a wen or an enlarged gland, may 
dispel it ; and such is the occasional result : in 
the same manner Perkinism, touching for the 
king's evil, &c. &c., become sorbcfacient agencies. 
It appears, consequently, that any thing of a 
physical or moral nature, which concentrates the 
vital activity on any part of the organism, may 
diminish the amount of nutritive exhalation in 
another part, and at the same time modify the 
function of absorption ; and that under this 
change in nutrition, parts may be reduced in bulk, 
morbid tumours disappear, and dropsical accumu- 
lations be absorbed. In this mode, methodical 
compression and friction operate as valuable 
sorbefacient or eutrophic agencies. 

In eutrophics, as a class, is comprised a number 
of valuable remedial agents, that may be adapted 
for various conditions of disease, which, as in the 
case of different cachexies, may have resisted 
other modes of management. Of these, one of 
the most important is m&cury, in its various forms 
of preparation. The precise nature of its action 
on the cconom/ has been a matter <3t dispute, h 



112 



EUTROPHIC-EXANTIIEMATA-EXPECTORANTS. 



certainly passes into the mass of blood, and 
doubtless, like eutroi)hics in general, modifies 
the condition of that fluid, so as to exert dyna- 
mically a new action on secretion and nutrition ; 
but as to the precise mode in which this is ac- 
complished, we know no more than we do of the 
modus operandi of other articles of the class, or, 
indeed, of any of the classes of therapeutical 
agents. It is impossible to depict every case in 
which this valuable agent is capable of affording 
benefit. It seems to be adapted for all cases in 
which it is desirable to induce a change in asso- 
ciated actions, and hence is an invaluable revellent 
in many febrile and inflammatory affections. As 
a eutrophic, it is chiefly indicated in chronic affec- 
tions, that are characterized by morbid depositions, 
or hypertrophies. 

The preparations of iodine are, likewise, admi- 
rable eutrophics ; well adapted for cases in which 
it is desirable to modify the state of the fluid of 
the circulation. Hence, they are much used in 
the various cachexiae, and for the removal of dif- 
ferent morbid growths. The reputation of iodine 
is most decided in goitre. In scrophulosis it has 
attained great celebrity ; and in certain of the 
constitutional forms of sypliilis has supplanted 
mercury. 

Burnt sponge, cod-liver oil, animal charcoal, 
chloride of calcium, chloride of barium ; the pre- 
parations of arsenic, of gold, and of silver, of pla- 
tinum and of iron ; as well as alkalies, and the 
mineral acids ; chlorine and chlorinated prepara- 
tions ; sulphur ; the free internal use of sugar : 
sarsaparilla; guaiacum-wood; mezereon ; the root 
of aralia nudicaulis ; bark of sassafras root ; dul- 
camara, &c., are the chief eutrophics now used. 
For the precise cases to which they are respec- 
tively adapted, and for the forms of preparation 
of these and other eutrophics that are most advisa- 
ble, the reader is referred to another work — (Gene- 
ral Therapeutics and Mat. Med. ii. 290, Philad. 

) ROBLEY DUNGLISON.] 

EXANTHEMATA.— The word exanthemata, 
ilerived from the Greek term i^avOiuo, to effloresce, 
or break forth, was applied, by the Greek writers, 
to cutaneous eruptions generally. By modern 
authors its application is confined to cutaneous 
eruptions accompanied with fever, arising from 
specific contagion. 

In the nosology of Cullen, the exanthemata 
constitute the third order of the class Pyrexiae, 
and we find he has included ten different genera, 
\'iz. variola, varicella, rubeola, scarlatina, pestis, 
erysipelas, miliaria, urticaria, pemphigus, and 
apkthcE- It is evident, however, he has included 
not only the eruptive fevers, strictly so called, but 
those diseases in which a vesicular efflorescence 
occasionally appears in their progress. Plenck, 
Frank, and others have fallen into a similar error. 
Willan and Bateman classify the exanthemata, 
according as the eruption agrees with their dcfini- 
vton of an exanthema or rash, viz. " superficial 
red patches, variously figured and diffused irregu- 
larly over the body, leaving interstices of a natural 
colour, and terminating in desquamation of the 
cuticle." They therefore comprehend, under ex- 
anthemata, rubeola, scarlatina, urticaria, roseola, 
purpura, and erythema. 



In the article Feveii will be found the classifi- 
cation of fevers we propose to adopt in this work, 
viz. into 1. continued; 2. periodic ; and 3. erup. 
tive. The eruptive fevers comprehend those dis- 
eases which wc submit should alone be included 
in the exanthemata, viz. variola (and its modifica- 
tions), rubeola, and scarlatina. In those diseases 
which bear a strong analogy to continued fever, 
we find that a certain order of febrile symptoms 
is followed by a particular eruption ; that the fever 
and exantheme run a definite course ; the efflores- 
cence going through a regular series of changes, 
and terminating in desquamation of the cuticle; 
that these eruptive fevers occur only once during 
the life of the individual ; and lastly, that they 
are communicated by contagion. 

The regularity of the eruptive fever and the 
progress of the efflorescence are most precise. 
The eruption of small-pox appears on the third 
day from the commencement of the febrile indis- 
position, and maturates on the tenth ; the rash of 
measles appears on the fourth, and declines on the 
seventh day ; and the efflorescence of scarlatina 
is visible on the second day, and begins to disap- 
pear on the fifth ; the progress of the fever being 
thus fixed and regular, and apparently keeping 
pace with the series of changes which the erup- 
tion successively undergoes. 

The circumstance that eruptive fevers occur 
only once in the course of life, though correct as 
a general rule, is liable to occasional exceptions. 
These, however, are comparatively so few, that 
they tend much to confirm this principle. Per- 
sons, on the other hand, occasionally escape one 
or more of the eruptive fevers ; more frequently, 
however, scarlatina than either small -pox or 
measles. 

The last characteristic of the exanthemata — 
that they are communicable by contagion — ad- 
mits of positive proof as to small-pox, in the com- 
munication of this disease by inoculation. 

Dr. Home (Clinical Experiments) succeeded in 
communicating measles by introducing the blood 
of a patient affected with the disease into the sys- 
tem of another individual ; and the evidence of 
the contagious nature of scarlet fever is so strong 
that no one in the present day ventures to im- 
pugn the doctrine. (See Measles, Scahlatisa, 
Small-Pox, and Vauicella.) 

A. TWEEDIE. 

EXPECTORANTS, (from ex and pectus; 
expectoro, expectorans, Expectorantia,') are medi- 
cines intended to promote the exertion of mucus 
and other substances from the trachea, its branch- 
es, and the bronchial cells. In offering this defi- 
nition, it is proper to mention that the existence 
of any substances capable of unloading the pul- 
monary tubes has been doubted ; but experience 
has demonstrated that not only substances applied 
in the form of vapour or of gas to the parts now 
mentioned, promote expectoration, but that sub- 
stances taken into the stomach produce the same 
effect. 

The mucous membrane of the air-tubes of the 
lungs is tlie part intended to be influenced by ex- 
pectorants. This membrane, which lines the 
whole of these tubes, from their origin through 
their trunk, the trachea, and all its ramifications, 



EXPECTORANTS, 



115 



to their termination in the bronchial cells, se- 
cretes a lubricating bland mucus, in appearance 
not unliice a thin solution of gum, intended to 
mitigate the action of the air on a highly irritable 
surface. When this mucus is accumulated, or 
becomes viscid and adheres to the sides of the 
broncliirtl tubes, or when it is inspissated or ren- 
dered acrid by inflammation excited in the mem- 
brane, so as to impede in any manner the function 
of respiration, then expectorants become useful 
by contributing to its removal. In etiecting this, 
they operate in two distinct ways; 1. they either 
diminish the action which has produced the pre- 
ternatural secretion, and thereby enable the natural 
effort of coughing to remove the morbid matter 
already existing in the air-tubes, or, 2. they di- 
rectly operate on the respiratory nerves, and pow- 
erfully excite those muscles, the sudden simulta- 
neous action of which is necessary for expelling 
the morbid matter. It is easy to conceive in what 
manner gaseous substances introduced into the 
lungs may promote this expectorant effort; but 
the question naturally suggests itself, do the sub- 
stances taken into the stomach proceed to the lungs, 
and there exert their influence ? 

Many substances, when introduced into the 
system through the stomach, escape by the lungs. 
Thus, various odorous matters, oil of turpentine, 
ether, alcohol, phosphorus, and camphor, soon 
after they are taken into the stomach, become per- 
ceptible in the breath ; and this is the case, also, 
when they are introduced into the system by 
other channels. M. Breschet and Dr. Edwards 
having injected oil of turpentine, in small quan- 
tity, into the crural vein of a dog, found that it 
was soon afterwards strongly exhaled from the 
lungs, although no odour of it was perceived on 
exposing the peritoneum.* From these and other 
facts it is evident that the lungs afford exit to sub- 
stances which have entered the circulation : now, 
in admitting this, it is not unreasonable to suppose 
that some of the medicines administered with the 
intention of promoting expectoration also enter 
the circulation, and proceeding to the lungs, ex- 
cite there the expectorant effort. But, although 
this conclusion be highly probable, yet it must be 
admitted that it is not susceptible of demonstra- 
tion. 

All expectorant substances may be arranged 
under two heads. — 1. Those which effect the ex- 
cretion by topical means; 2. those which effect 
it by general means. 

1. Topical Expectorants. — These may ope- 
rate in two ways: a. they may directly stimulate 
the nerves regulating the action of the respiratory 
muscles, and, by exciting these to sudden action, 
may effect the excretion by coughing ; or, b. they 
may com[)ress the thoracic viscera by producing 
vomiting, and thus induce a sudden and forcible 
expiratory cflort so as to effect the expulsion of 
matters from the lungs. 

a. In explaining the manner in which the first 
kind of topical expectorants operate, it may be 
useful to consider briefly the nature of coughing. 
The act of coughing is a short and forcible expi- 
ratory effort, frequently repeated, the inspirations, 



* During this experiment, if a portion of the surface 
was doiMicleil an<l a cuppinji-glass applierl over it, the 
odour was not thfii perceptible in the breath. 
Vol.. II.— 15 K« 



in the intervals, being trifling in comparison with 
the expirations. Any irritation affecting the glot- 
tis, and acting upon a branch of that series of 
nerves which supply the respiratory muscles, ex- 
cites involuntary coughing; but the action thus 
excited may be moderated, if it cannot be wholly 
checked and terminated, by the will of the indi- 
vidual. Coughing, whether voluntary or invol- 
untary, is the result of the irritation of a certain 
set of nerves, and is intended to relieve the bron- 
chial system of some offending cause ; it is, there- 
fore, a salutary phenomenon. In those debilitated 
by disease or other causes, the difliculty of excit- 
ing the act of coughing with force sufficient to 
produce the salutary effect, is so obvious as to 
strike the ordinary as well as the professional ob- 
serA'er. The distress arising from this circum- 
stance, the uneasiness caused by the irritating 
matters which coughing forcibly would readily 
remove, and the feeling of suffocation experienced 
from the accumulation of mucus obstructing the 
free passage of the air to the bronchial cells, are 
very considerable. In such states of the chest, 
the topical application of a stimulant to the bron- 
chial nerves may so far rouse the exhausted excita- 
bility as to enable the muscles to perform the ne- 
cessary effort ; whilst, at the same time, the sub- 
stances employed to produce this effect may be of 
a nature to prove also beneficial, by imparting a 
renewed healthy action to the diseased mucous 
membrane. The whole of the substances arranged 
under this head, it must be recollected, stimulate 
so much as to require the utmost caution in their 
administration; but as the atmospherical air is 
the vehicle by which they are conveyed into the 
lungs, there is no difficulty in apportioning the 
degree of dilution so as to regulate the quantity 
of stimulus required or admissible. 

The substances employed for the purpose of 
stimulating the mucous membrane of the bron- 
chial system by direct application, and through it 
stimulating the respiratory organs, are few, and 
of these a small proportion only are in use. 

Benzoic acid may be employed either in its 
separate pure form or at the instant of its extri- 
cation from benzoin. In either case it requires to 
be largely diluted with atmospherical air, and 
combined with aqueous vapour. If the crystal- 
lized acid be employed, half a drachm should be 
put into an inhaler, and volatilized by the heat of 
a spirit-lamp ; or if the crude benzoin be prefer- 
red, half an ounce of it should be broken into 
small morsels and treated in the same manner. 
In the first instance, the diluted acid is the stimu- 
lating agent ; in the second, the volatile oil, mixed 
with a small portion of the acid, rises with the 
aqueous vapour. Both are said to have proved 
beneficial in phthisis, even after the existence of 
suppurating tubercles had been clearly ascertain- 
ed. The writer of this article has never employed 
these stimulants in phthisis; but he has seen 
much advantage derived from them tn spasmodic 
asthma, in shortening the paroxysm and promot- 
ing expectoration. 

Acetic acid acts nearly in the same manner as 
the benzoic. It is the oldest of the topical reme 
dies of this .order, is more manageable than the 
acid of benzoin, and does not require the aid o 
boihng water for its elevation. It is usually ex 



114 



EXPECTORANTS. 



tricated from diluted vinegar ; but as this contains 
sulphurous acid, distilled vinegar should be em- 
ployed. 

Chlorine is of very late introduction as a topi- 
cal expectorant. It may be breathed by mixing 
it with the common air of the apartment of the 
patient, at the moment of its extrication from 
chloride of lime or of soda ; or from a mixture of 
one part of peroxide of manganese and four parts 
of muriatic acid.* The former is to be preferred 
when a moderate stimulus only is required ; but 
in general, for expectorant purposes, chlorine is 
obtained by expelling it from its saturated solution 
in water by the aid of gentle heat. 

If an attempt be made to breathe chlorine in 
its undiluted state, it does not enter the lungs, 
but produces a powerful spasm of the glottis; 
and, if this be not immediately relaxed, suffoca- 
tion ensues. When it is diluted with a mode- 
rate portion of air, it excites violent coughing, 
irritation in the bronchial cells, great dyspnoea, 
and a painful, anxious sensation in the chest, 
which continues for several days. When largely 
diluted it operates as a salutary stimulus to the 
mucous membrane. 

In its largely diluted state, chlorine gas was 
first proposed as a topical expectorant by Dr. Fa- 
vart of Marseilles in 1804. Soon after that pe- 
riod the writer of this article became accidentally 
acquainted with its value as a topical expectorant, 
from witnessing its beneficial influence in a severe 
case of epidemic catarrh, when extricated as a 
fumigation to check infection ; and he has em- 
ployed it occasionally from that time in pulmo- 
nary diseases. But it was scarcely used either in 
this country or on the continent, until a report 
of Dr. Cottereau, of the Faculty of Medicine of 
Paris, again brought it before the profession. Sev- 
eral trading chemists, in particular M. Gannal, 
had remarked that phthisical persons, who en- 
gaged themselves to work in the manufactories of 
bleaching liquor, in which chlorine is largely ex- 
tricated, veere gradually but evidently improved 
in health : to confirm his observations, M. Gannal 
constructed an instrument for inhaling it, and ac- 
tually administered it as a remedy in phthisis. 
The success of his experiment surprised him ; 
but not being a medical man, he mentioned his 
views of the subject to Dr. Cottereau, who pur- 
sued the same plans as M. Gannal, and with a 
degree of success sufficient to merit the attention 
of the profession. The same influence of chlo- 
rine in pulmonary diseases has been observed by 
Mr. Tenant, of Glasgow, who informs us that all 
the men who engage themselves to work in his 
manufactory, if they have coughs, are rapidly re- 
lieved when gradually introduced into the chlorine 

* In this process the miiri.Ttic aciJ, which is a com- 
pound of hydrogen and chlorine, is parti.illy decompos- 
ed; and decomposition of the peroxide of'manganese 
also takes place. The liberated hydrogen of the muri- 
atic acid unites with one equivalent of the oxygen of 
the peroxide of manganese, and forms water; whilst 
the chlorine is set free in a gaseous state. This gas is 
of a greenish yellow colour, and has a pungent, acrid, 
suffocating odour. It is really absorbed by water; but 
the solution, unless kept in a Llackened bottle or a dark 
place, is changed in its character by slow decomposition 
of the water and the formation of chloric and muriatic 
acids. Its goodness is known by testing ii with litmus 
paper: if good, it will destroy the colour of the paper; 
if it contain the above-mentioned acids, the paper will 
be reddene/l. 



house : and of late, people labouring under phthi- 
sis and asthma have taken lodgings in the neigh- 
bourhood of his works, for the sake of the atmo- 
sphere of chlorine emanating from them. 

[Farther experience has not, however, confirmed 
these favourable reports, and .some writers of dis- 
tinction have regarded it to be prejudicial in 
phthisis. (See the writer's New Remedie/i, 4th 
edit. p. 151, Philad. 1843.) In all cases it has to 
be employed carefully and experimentally; but 
no marked benefit can be expected from it in 
phthisis. It can only be adapted for cases of dis- 
ease in which the pathological condition of the 
bronchial mucous membrane, or neighbouring 
parts, requires the exhibition of an excitant. In 
this way, it may be occasionally serviceable in 
chronic bronchitis.] 

The best method of inhaling chlorine is to put 
f.^i or f.^ii of the saturated aqueous solution into 
a glass inhaler, and add to it f.^ii of hot water, 
which gradually drives off the chlorine. This 
quantity may be inhaled every five or six hours, 
so as to maintain the effect produced on the mu- 
cous membrane. 

[A convenient apparatus for the inhalation of 
chlorine, iodine, &c. has been prepared by Dr. 
Corriagn of Dublin. It is figured in the writer's 
Neiv Remedies, loc. cit., and in his General The- 
rapeutics <Sr Mai. Med. i. 253, Philad. 1843.] 

When it is thus cautiously inhaled, the evident 
effects are a slight sensation of constriction in the 
thorax, with some increase of cough ; in a few in- 
stances a trifling degree of vertigo has been expe- 
rienced, but these feelings rapidly subside ; expec- 
toration is produced almost without an effort, and 
the patient gradually becomes more comfortable 
than before inhaling the gas. In cases of asthma 
the relief is peculiarly striking; and in phthisis 
we have observed that the symptoms of hectic 
have much abated during its employment: but we 
have seen no instance of the latter disease cured 
by it. 

The beneficial operation of chlorine may depend 
on its stimulus producing a new action on the 
diseased surface, which, if it could be maintained 
for a sufl'icient length of time, might overcome the 
morbid action ; and by supporting the tone of the 
system by other means, without exciting fever, the 
disease might be cured. In cases where large vo- 
micse exist, it is in vain to expect a cure from any 
means ; but if we reflect on the influence of chlo- 
rine in improving the discharge from diseased 
mucous surfaces, such as that of the nostrils in 
coryza, and in promoting the cure of external ul- 
ceration, it is not a vain speculation to expect 
much advantage from its inhalation in phthisis. 

When chlorine is inhaled without being suffi- 
ciently diluted, the irritating effects are only tem- 
porary : very few instances have occurred in which 
inflammation has supervened. Indeed to no other 
irritant gas does the pulmonary system so rapidly 
accommodate itself; the workmen in the manu- 
factories of bleaching liquor brc;ithe it daily in 
large quantities with impunity. The best method 
of overcoming its deleterious effects is to inhale 
ammonia largely diluted with aqueous vapour or 
ether; or, if neither of these be at hand, to inhale 
simple warm vapour. 

[The inhalation of iodine has been recommended 



EXPECTORANTS. 



115 



as an excitant topical expectorant in the same 
diseases as that of chlorine. It has been strongly 
advised in phthisical affections. Sir C. Scuda- 
mere {Lond. Med. Gaz. Feb. 17, 1838, and Feb. 
7, 1840) found the addition of a little tincture of 
coniutn beneficial in subduing the irritating quaU- 
ties of the gas. The writer — as elsewhere re- 
marked — has often used the iodine inhalations in 
phthisis, but his experience has not been favourable 
to it, and the same view has been entertained by- 
others. (Pereira, Elements Materia Medico, 2d 
edit. i. 29-5, Lond. 1842.) It would seem to be 
better adapted for chronic bronchitis.] 

The substances which operate topically, either 
by stimulating the pulmonary exhalents, or as se- 
datives relieving the constriction on these vess6ls, 
and thereby facilitating expectoration, are also 
few. In those unaccustomed to the use of the 
former, they undoubtedly excite coughing; but in 
such cases the spasmodic action is produced by 
their first impression on the glottis, for when they 
are admitted into the tracliea, no coughing is pro- 
duced. The first of these, the fumes of boiling 
tar, was recommended as a remedy in phthisis by 
Sir Alexander Crichton, who had seen it em- 
ployed in Russia. It produces in general much 
increase of cough ; but this soon abates, and the 
expectorated matter is, in most instances, much 
improved. These effects seemed to promise the 
most salutary results ; but like some other reme- 
dies which have been occasionally introduced to 
the notice of the profession, the vapour of tar suf- 
fered from being overpraised, and from too san- 
guine expectations being formed relative to its 
powers, and it fell into neglect. 

[Creasofe, like tar vapour, has been occasion- 
ally inhaled in the same pulmonary affections ; 
five, ten, or fifteen drops, according to the degree 
of tolerance of the lungs, being dropped into hot 
water in an appropriate vessel, and the vapour be- 
ing inhaled through the tube of an inverted funnel, 
or by means of any of the inhalers in use.] 

Another vapour which operates nearly in the 
same manner as that of tar has been much em- 
ployed in America, the fumes arising from burn- 
ing undressed wool. The use of these vapours 
was first recommended by Dr. Physick, who had 
found them extreme!}' serviceable for stimulating 
and healing external sores, and concluded that 
they might prove equally beneficial if inhaled into 
the lungs. He conceived that he had established 
the fact of their utility in phthisis; but the experi- 
ence of a few instances in which they were tried 
by the writer of this article does not authorize 
him to pronounce very favourably respecting their 
employment. They excited great coughing when 
they were first used ; but this rapidly subsided, 
and some degree of comfort was certainly experi- 
enced after each time of inhaling them ; but 
nothing more resulted from their employment. 

The sedative topical expectorants are better 
known. Tobacco, when smoked, has been long 
employed for allaying the violence of the paroxysm 
in spasmodic asthma ; but it is uncertain whether 
the benefit should be ascrihed to the nicotina or 
the volatile oil. The use of stramonium, in the 
form of smoke also, has been found highly useful, 
and was at one time a favourite remedy in asthma. 



It appears to produce its beneficial effect in two 
ways. In the first place, it is directly applied to 
the mucous membrane when this is in a state of 
great irritability, and by acting as a sedative and 
allaying this condition, it favours the slower and 
more perfect secretion of the mucus, which being 
thus brought into a more natural state, is conse- 
quently more easily excreted : in the second place, 
by influencing generally the nervous system, the 
spasmodic symptoms attendant on the paroxysm 
of asthma are allayed, and respiration proceeds in 
a calm and undisturbed manner. The powers of 
stramonium were, at one time, greatly overrated ; 
but experience has sufficiently demonstrated that 
it is capable of mitigating the violence of the pa- 
roxysms, although it may not be able to establish 
permanent relief from their attacks. Dr. Bree 
has objected to the employment of stramonium on 
the supposition that it induces a tendency to apo- 
plexy ; but this is, at best, problematical. 

b. The second set of topical expectorants, those 
which operate by mechanically compressing the 
thoracic viscera, and thus induce a sudden and 
forcible expiratory effort, so as to affect the expul- 
sion of matters from the lungs, are emetic sub- 
stances. In the operation of vomiting, by the 
sudden and violent contraction of the abdominal 
muscles, in order to force the contents of the sto- 
mach upwards, an impulse is communicated to 
the whole bronchial system, and by this means 
the expiratory effort being rendered more forcible, 
the expulsion of the mucus is effected. The bene- 
ficial effect of emetics in clearing away mucus 
accumulations from the lungs is indeed well 
known ; and frequent recourse is had to them in 
many of the pulmonary diseases of children with 
uniform advantage. It might be supposed that 
the best emetics to select for expectorant pur- 
poses, would be those which operate by directly 
stimulating the nerves of the stomach, and which 
call the muscles necessary in the mechanism of 
vomiting into immediate action ; but experience 
has demonstrated that the antimonial preparations 
are better suited for this purpose than any other 
emetics. Besides aiding the expulsion of mucus 
from the bronchial tubes, they possess the power 
also of controlling inflammatory action. The 
employment of emetics for procuring expectoration 
was formerly in much vogue as a remedy in 
phthisis. The emetics for this purpose, however, 
were seldom selected upon any principle : at one 
time we find sulphate of zinc and sulphate of 
copper employed ; at another, antimonials, ipeca- 
cuanha, and other nauseating emetics. If the 
lungs be loaded with mucus, and little or no 
febrile action be present, the direct emetics are to 
be preferred ; for in this case the mechanical im- 
pulse only is required ; but if, in promoting expec- 
toration, we are desirous of maintaining nausea 
afterwards, then the best emetic is the vinous solu 
tion of the tartrate of antimony and potassa, given 
to the extent of f^vi for a dose, in a solution of 
the extract of liquorice. Squill and sulphuret of 
potassa have also been employed to excite vomit- 
ing to aid their expectorant properties. 

2. General Sxpectorantst — These operati< 
cither by being received into the circulation, or 
through sympathy with the stomach : the fire" 



116 



EXPECTORANTS. 



stimulate the pulmonary exhalents through the 
medium of the circulation ; the second aftect the 
excretorics by the nausea which they induce. 



chronic coughs and catarrhal affections of Jebili- 
tated habits ; but in these cases more is due to its 
tonic than its expectorant influence. It is fre- 
quently prescribed with the view of supporting 



n The first of the organic substances which ,, ^ , <• 1..1 ■■ 



is emetina, the active principle of ipecacuanha. 
In its uncombined state it has not been much em- 
ployed in Britain; but in France it has been 
successfully administered in doses of one-eighth 
of a grain, three or four times a day, in hooping- 
cough ; and in doses of a quarter of a grain it 
proves useful in catarrhal affections. It produces 
expectoration without exciting nausea ; and we 
can readily comprehend how this is effected, if 
we admit that it is received into the circulation 
and determined to the lung as its emunctory : but 
if this be not admitted, it is difficult to explain its 
mode of acting : — its beneficial influence is un- 
doubted. When ipecacuanha itself is administered, 
it is usefully combined with opium, in the form of 
Dover's powder, of which from three to five grains 
produce expectorant effects, when neither nausea 
nor diaphoresis result. The French physicians 
assert that ipecacuanha is less useful in pulmonary 
diseases than uncombined emetina, owing to a 
peculiar fatty matter which it contains interfering 
with the influence of the emetina. This opinion 
is merely hypothetical ; but nevertheless the evi- 
dence which experience has afforded in favour of 
the expectorant power of emetina is sufficient to 
recommend it to the favourable notice of British 
practitioners. 

The value of squill as an expectorant has been 
long known : it is supposed to depend on a pecu- 
liar principle which has been named scillitina. If 
this opinion be correct, it is probable that the squill 
undergoes decomposition in the stomach, and that 
the scillitina only is conveyed to the lungs. This 
opinion, however, is as yet unsupported by proof; 
and much obscurity still involves the mode in 
which squill produces its expectorant effect. Squill 
is contra-indicated in all diseases of an inflamma- 
tory type. It is usually administered in combina- 
tion with honey and vinegar in the form of an 
oxymel, or in tincture, or as a pill in combination 
with soap and ammoniacum. In these forms it is 
prescribed with advantage in asthma and chronic 
catarrh. The dose should not exceed one grain 
of the dried bulb, as in larger doses it is apt to 
prove emetic, purgative, or diuretic : one drachm 
of the oxymel, seven grains of the pill, and thirty 
minims of the tincture, are equivalent to this 
quantity of the dried bulb. When over-dosed, 
squill excites the most violent vomiting, purging, 
and convulsions, symptoms which induced Orfila 
to refer its operation to the nervous system ; an 
opinion partly confirmed b}^ the fact that dissec- 
tions of persons poisoned by squill present no 
appearances of inflammatory action in the pulmo- 
nary system. The best antidotes are ammonia 
and the alkalies, on which account these sub- 
stances are incompatible in prescriptions with 
fcquill. 

Several of the gum resins are generally regarded 
• s useful expectorants, but the expectorant pro- 
perty of some of them is doubtful. Myrrh is one 
of these, and assuredly we have never seen it pro- 
tiuce expectoration when given alone : conjoined 
'%'ith ipecjj-uanha or squill, it proves useful in the 



and, probably, no medicine is better adapted for 
this purpose during a course of the inhalation of 
chlorine. At best, however, it can only be regarded 
as an auxiUary. In prescribing myrrh, it should 
be recollected that its aqueous infusion precipitates 
salts of lead, which are, consequently, incompati- 
ble in mixtures with it. In phthisis it is advan- 
tageously combined with sulphate of zinc or salts 
of" iron ; and when there is much acidity of sto- 
mach, it may be dissolved in liquor potassae or 
ammonifB, and administered in any bland fluid or 
aqueous solution, such, for instance, as the bitter 
almond emulsion. Its efficacy as an auxiliary is 
well established in chronic catarrh and humoral 
asthma, in both of which diseases its tonic influ- 
ence is beneficial in relieving the exhaustion which 
follows the profuse expectoration. The dose of 
myrrh, in such cases, is from four to ten grains, 
repeated every third or fourth hour. 

As an expectorant, ammoniacum has been 
found useful in asthma, peripneumonia notha, 
and the chronic catarrh of old age; it has also 
been prescribed in tubercular phthisis. It is seldom 
given alone, but usually in combination with squill 
or antimonials. In America it has lately been 
conjoined with nitric acid : two drachms of it are 
triturated with f gii of nitric acid, and then formed 
into an emulsion with f.^viii of water. A table- 
spoonful of this solution in a cupful of any bland 
fluid is administered every second or third hour, 
in cases of old catarrhs, when there is an infarc- 
tion of the lungs with viscid mucus, which the 
patient has not strength to expectorate. It may 
in this state certainly rouse the energy of the 
respiratory muscles ; but we doubt whether it is 
equal to ammonia or its carbonate in such cases. 
It may, however, be administered in conjunction 
with ammonia ; and, when thus combined, no 
other expectorant produces so much benefit in 
those irritable coughs which accompany hysterical 
affections, and are attendant on dyspeptic and 
hypochondriacal conditions : the expectoration 
becomes freer and more abundant, the oppression 
diminishes, and the patient is rendered altogether 
more comfortable. Ammoniacum, Galen inlorms 
us, was employed by Crito as an expectorant in 
phthisis ; it formed the chief ingredient of the 
pilulae balsamicas of Morton, which held at one 
time a high reputation ; and many other writers 
have recommended it in this merciless disease. 
It may prove useful in promoting expectoration 
where it is deficient, and may have a tendency to 
allay irritation ; but the experience of modern 
practitioners has not confirmed the encomiums of 
their predecessors with respect to its value as a 
remedy in phthisis. The dose of ammoniacum, 
in these cases, is from eight to ten grains, admi- 
nistered three or four times a day. In large doses 
it causes nausea, thirst, and a sensation of heat at 
the stomach. The emulsion is the best form of 
administering ammoniacum as an expectorant; 
but as the gummy matter is not sufficient to sus- 
pend the resin for any length of time, it should be 
combined with mucilage. The dose of the mix- 



EXPECTORANTS. 



117 



ture is from f.^ss to f.gi: it is coagulated by the 
oxymels, and cannot be combined with spirit of 
nitrous ether. 

Assafcctida was regarded by Cullen as superior 
to ammoniacum in spasmodic asthma ; and in 
phthisical cases, when there is mucli flatulency, 
Dr. Parr considers it valuable as combining cardiac 
and expectorant properties. It possesses, however, 
no advantages over ammoniacum, and is more 
heating : indeed, what has been said of ammonia- 
cum applies equally to it, galbanum, and sagape- 
num : they are all stimulant expectorants, and 
may be administered, under similar circumstances, 
in the same doses and in the same manner. 

The balsams employed as expectorants are those 
of tolu and peru, styrax, and benzoin. All of 
them were formerly much used in affections of the 
chest, whether recent or chronic ; but there can be 
only one opinion respecting the impropriety of 
administering balsams in inflammatory states of 
the lungs. Independently of the benzoic acid 
which they all contain, and which is powerfully 
stimulant, the volatile oil, which is another of 
their components, contra-indicates their adminis- 
tration in cases of excitement. Dr. Fothergill 
denounces the employment of balsams in pulmo- 
nary diseases at any period of the attacks, but he 
carried his objections too far ; and there is suffi- 
cient evidence to prove, that after the excitement 
is subdued, there are circumstances which not 
only admit of the administration of balsams, but 
in which they have been found highly beneficial. 
They are best administered in the form of emul- 
sion, made by triturating the tincture of the bal- 
sam with mucilage of acacia gum, which renders 
it miscibie with water ; and in this form they may 
be usefully combined with ipecacuanha and pre- 
parations of opium. Copaiba, which is impro- 
perly regarded as a balsam, may be exhibited 
under similar circumstances. It is probable that 
it acts on the mucous membrane of the bronchial 
tubes, in nearly the same manner as on that of 
the urethra in gonorrhoea, by entering the circula- 
tion, and exciting a new action on the irritated 
surface. It is only by admitting that it operates 
in this manner, that we can account for the benefit 
which frequently results from its administration in 
the advanced stages of phthisis. 

Among the plants yielding bitter extractive in 
combination with mucus and fecula, employed as 
expectorants, we find marrubium vulgare, tussi- 
Idigo farfara, and certraria Islandica. If the first 
of these, the horehound, was too much vaunted 
by the ancients, its expectorant properties have 
been unaccountably neglected by modern British 
practitioners. It possesses stimulant powers, al- 
ters the state of the bronchial secretion, and seems 
to impress a new action on the diseased surface ; 
besides promoting expectoration, it diminishes the 
oppression of the chest, relieves dyspnoea, and im- 
proves the digestive function. We have seen 
much advantage result from its employment in hu- 
moral asthma, accompanied with great oppression, 
and when the sputa was tough, ropy, difficult to 
be expelled, and causing pain in the expectora- 
tion. Many authors, as well as Tralles, have re- 
commended marrubium in phthisis. Although we 
have had no reason to place any reliance on its 
powers in tubercular consumption, yet we have 



witnessed much benefit produced by it in that va- 
riety of the disease which has been named catar- 
rhal, in which there is much cough, with copious 
excretion of mucus; a diurnal fever recurring 
twice a day, nocturnal sweats, and great prostra- 
tion of strength. In this state the combination of 
the expectorant and tonic powers found in marra- 
bium have proved highly beneficial. The dried 
plant may be administered in the form of povvder, 
mixed with syrup of white poppies, or in the form 
of an aqueous or a vinous infusion. The aqueous 
infusion may be made with ^i of the dried plant 
and a pint of boiling water; the dose is f.^ii, 
given three or four times a day. 

Tussilago furfura, coltsfoot, has been as much 
neglected as horehound by the moderns, although 
it held the first rank as a pectoral among the an- 
cients : indeed its name (tussilago is a com- 
pound of tussis and ago') speaks the estimation in 
which it was formerly held. Although it has not 
deserved the praise bestowed upon it by the an- 
cients, yet tussilago possesses expectorant proper- 
ties by no means contemptible. As a gentle tonic 
expectorant, the writer of this article can bear 
ample testimony to its influence in the sequel of 
hooping-cough, when the habit is greatly weakened 
and the coush continues ; and he has seen it equal- 
ly beneficial in many cases of chronic catarrh. It 
is best administered in the form of decoction, in 
making which, care should be taken to strain care- 
fully, as the hairs of the pappus of the flowers 
sometimes irritate the gullet and excite much un- 
easiness there. It cannot be prescribed in combina- 
tion with acetate of lead. 

Cetraria Islandica, or lichen Islandicus, or 
Iceland liverwort, or Iceland moss. Notwithstand- 
ing the encomiums which have been passed upon 
it by Scopoli, Hertz, Schneider, Stoll, Wansdorff, 
Sir Alexander Crichlon, and other justly distin- 
guished physicians, it is doubtful whether this plant 
possesses any expectorant influence. " In phthi- 
sis, " says Sir Alexander Crichton, "its good ef- 
fects consist in improving the matter to be expec- 
torated; in diminishing the frequency of the 
cough, and rendering it more easy ; in calming 
the irritability of the patient, and in preventing or 
much moderating hectic fever. " (London Medi- 
cal Journal, vol. x., page 229. ) He, however, 
admits that it did not fulfil his hopes, in the cases 
which he saw treated with it at Vienna ; and we 
have never seen any benefit derived from its use 
as an article of diet. In preparing it, the bitter 
should not be entirely extracted ; as, in that case, 
it is merely a nutritive substance, well calculated 
for phthisical patients, but possessing no medici. 
nal influence. 

Among the inorganic substances of this divi- 
sion of expectorants, ammonia and its carbonate 
are admirably adapted to free the bronchial system 
from the load of mucus which oppresses it, after 
attacks of acute pneumonic inflammation in de- 
bilitated habits, especially when the expectoration 
suddenly stops and suffocation is threatened. They 
operate by the influence which they exert on the 
nervous system, without augmenting, in an equal 
ratio, the action of the heart and arteries. The 
dose of both preparations must be regulated by 
circumstances : that of the carbonate may be car- 
ried to gr. X. or even gr. xv., and repeated everr 



118 



EXPECTORANTS 



secontl hour until the effect is produced; after 
which ihe dose should be diminished and the inter- 
vals extended. Owing to the heat of fauces which 
It causes in the act of swallowing, it should be 
involved in some mucilaginous substance, such, 
for instance, as a combination of the compound 
powder of tragacanth in almond emulsion. 

b. The general expectorants which affect the 
pulmonary excretories by the nausea which they 
induce, are few in number. In attempting to ex- 
plain their mode of operating, we must take in+o 
consideration the similarity between the function 
of the skin and that of the mucous membrane of 
the bronchial tubes. Both are exhalent organs ; 
and both, in febrile and inflammatory states of the 
system, are liable to suffer constriction capable of 
impeding their exhalent function, and giving origin 
to a train of symptoms depending on a deficiency 
of the natural lubricating mucous secretion. In 
this condition of the mucous membrane, antimo- 
nials and nauseating remedies relax this constric- 
tion, and enable the secretion to proceed ; but 
still it may be demanded — in what manner do 
such nauseants promote expectoration 1 It is pro- 
bable that, during the state of constriction of the 
bronchial exhalents, any mucus then existing in 
the air-tubes is of a very acrid character ; but as 
it remains adherent, it excites no effort for its ex- 
pulsion : when, however, the constriction is relaxed, 
and it becomes diluted and moveable, it still re- 
mains sufficiently acrid to stimulate the glottis 
and larynx, and thus to call into sympathetic action 
the whole set of respiratory muscles requisite for 
the effort of coughing, to expel the now loosened 
mucus. This explanation is not completely satis- 
factorj-; it explains the mode in which the viscid 
mucus is diluted, but not well that by which it is 
expelled. 

Among the antimonials, the precipitated sul- 
phuret was formerly much employed in asthma 
and chronic catarrh, but the uncertainty of its 
operation has greaily narrowed the chances of its 
influence proving beneficial ; and as tartar-emetic 
answers every indication, it is now generally pre- 
ferred. For expectorant purposes, tartar-emetic 
is given in minute doses ; for instance, from one- 
tenth to one-fourth of a grain, repeated at short 
intervals. In order to secure its expectorant effect, 
the surface of the body should be kept moderately 
warm. It is sometimes combined with squill and 
other vegetable expectorants; but these combina- 
tions improve neither the powers of the tartar- 
emetic, nor those of the other matters with which 
it may be combined. Its influence, however, is 
augmented by the addition of opium, which has 
been erroneously supposed to diminish the bron- 
chial exhalation ; on the contrary, it not only aids 
other expectorants, but promotes it when given 
alone : an effect which is to be attributed partly 
lo us increasing the natural secretion of the mu- 
cous membrane, partly to its sedative property di- 
minishing the irritability of that membrane. 

Before closing this article, it is necessary to 
offer a few remarks on the circumstances which 
should regulate us in our selection of expectorants. 
The first object is to ascertain the nature of the 
cough whf*her it be connected with a state of 
Inilammatory action in the pulmonary organs, or 
wvth one of debility ; and in that case, whether it 



be kept up by nervous irritation. In every pul 
monary disease attended with cough, there is rea 
son for thinking that the early symptoms are those 
of inflammation ; at that period, therefore, expec- 
torants are of little value, except as auxiliaries in 
bringing on a crisis ; but after the inflammation 
is partly subdued, then the most salutary effects 
are obtained from expectoration. In this stage of 
the disease, the nauseating expectorants are to be 
preferred ; but when the inflammatory action is 
wholly subdued, those stimulating substances 
which we have described as calculated to produce 
the expiratory effort necessary to throw off the 
load of mucus with which the lungs are oppressed, 
are then required. It is easy to conceive that 
thickened, or, as they are termed, well concocted 
sputa, which are generally sufficiently glutinous 
to adhere together in masses, will be more easily 
detached and ejected by coughing than a thin 
mucus, whether accumulated in the tubes, or 
spread out upon their sides. The necessity, there- 
fore, of ascertaining whether the disease be one 
of excitement or debility is essential : it is neces- 
sary, also, to take into consideration the period of 
the attack, whether it be the commencement, 
middle, or termination, when we are called upon 
to prescribe ; for although each of these periods 
may be benefited by expectoration, yet the sub- 
stances employed to effect this require to be very 
different in their characters, according to the period 
in which they are given. In illustration of this 
point, we have only to take as an example a case 
of pneumonia. In the commencement of the at- 
tack the bronchial tubes are comparatively dry 
but if this state be overcome, either by the use of 
the lancet, or by a tendency to a spontaneous 
crisis, the quantity of mucus is then preternatu- 
rally increased, and is often tinged with blood. 
The most favourable symptom in this state is a 
free expectoration ; the most unfavourable, the 
sudden cessation of it. Our object, therefore, 
should be to aid this effort of nature, or to produce 
an artificial state resembling it; not with the view 
of throwing off morbific matter, but upon princi- 
ples of a sounder pathology. In the commence- 
ment of the attack, if there be any reason for en- 
deavouring to promote expectoration, it must be 
effected by the gentlest means ; such, for instance 
as the inhalation of warm aqueous vapour, or by 
nauseating doses of ipecacuanha, tartar-emetic, 
and opium. Full vomiting, in this state of the 
chest, is also, occasionally, highly beneficial; and 
although, on a prima-facie consideration of its 
mode of action, it may seem a't variance with the 
means just recommended, yet, by favouring a 
transfer of action, it often induces an increased 
secretion of mucus from the pulmonary exhalents, 
productive of the most marked relief. To effect 
this benefit, however, the vomiting must be full 
and mamtained for a specific time, certainly not 
less than an hour. If, notwithstanding the em- 
ployment of these means, the expectoration be- 
come too abundant, so as to obstruct the free 
entrance of the air into the lungs, then the stimu- 
latmg expectorants are indicated, squill, ammonia- 
cum, the balsams, ammonia, and the topical appli- 
cation of the expectorant gases. 

The nauseating expectorants are equally indi- 
cated in the commencement of catarrhs, especially 



EXPECTORANTS — EXPECTORATION. 



119 



in the epidemic variety termed influenza. After 
bleeding moderately, and the administration of an 
emetic, the best results have followed the employ- 
ment of small doses of ipecacuanha, in combina- 
tion with squills and opium ; but when the febrile 
symptoms have disappeared, and cough attended 
with a thin frothy excretion only remains, the 
balsams, gum-resins, and opium, administered in 
the evening and at bed- time, _ prove generally 
highly beneficial. The same precautions are re- 
quisite in the administration of expectorants, in 
the commencement and in the advanced stages of 
phthisis. In the greatest number of cases of 
asthma of a recent date, some degree of inflam- 
mation is present; but from the progress of the 
paroxysm, and its termination in expectoration, 
an erroneous notion was entertained that the solu- 
tion of tlie paroxysm must necessarily follow its 
appearance ; and, consequently, squill, ammonia- 
cum, and other stimulants, instead of the nau- 
seating expectorants, were inconsiderately pre- 
scribed, and often produced injurious consequences. 
In that variety of asthma, however, which appears 
to depend on a state approaching to that of para- 
lysis of the system of the par vagum, in which 
the bronchial cells, being deprived of their nervous 
energy, do not contract sufficiently to aid the ex- 
pulsion of the air in expiration, and, instead of 
aiding, prevent the necessary change of the blood 
in the pulmonary circulation, the nauseating ex- 
pectorants prove hurtful, by keeping up that state 
of diminished excitability which is the result of 
the morbid condition of the bronchial nerves. It 
is in such cases, and in the low stage of pneumo- 
nic inflammation, when the febrile symptoms as- 
sume a typhoid chai'acter and the lungs are loaded 
with mucus, that the inhalation of the expectorant 
gases, the internal administration of the balsams, 
and more especially of ammonia, prove undoubt- 
edly beneficial. 

[Almost every class of medicinal agents may 
become expectorant according to the precise con- 
dition of the system generally, or the pulmonary 
organs particularly ; and hence we find an expec- 
torant effect equally firom depletives, and from 
tonics and excitants ; from narcotics and counter- 
irritants ; and from nauseants and emetics.] 

Under all circumstances there are three general 
rules to be kept in view in administering expecto- 
rants : 

1. The surface of the body should be kept mo- 
derately warm, and even in a gentle or breathing 
perspiration. 

2. Whatever determines to the kidneys must 
be avoided. 

3. Purging is not only not to be promoted, but 
to be most carefully guarded against; for as the 
action of the secreting vessels of the lungs and 
those of the intestines are opposed to one another, 
expectoration is checked when purging occurs. 

A. T. Thomson. 

EXPECTORATION.— This word (from ex 
and pectus, strictly signifies the act of discharg- 
ing any matter from the chest, but by a figure of 
speech it is also commonly applied to the matters 
discharged from the lungs and air-tubes. 

The act of expectoration is one of the instances 
ot combined movement in the respiratory machine, 



which, by an admirable and harmonious consent 
between its numerous muscles, unerringly pro- 
duces such a variety of actions. The function of 
respiration is of such vital importance that accu- 
mulations or effusions which obstruct it endanger 
life itself. The structure of the bronchial tree 
contributes greatly to the easy removal of any 
superfluous matter in it that might cause such 
obstruction, for the sum of the area of its branches 
being considerably greater than that of the trunk, 
or of the trachea, the air commonly finds easy en- 
trance into the air-cells, and, on its more rapid 
return in expiration, carries with it the super- 
fluous matter. Thus ordinary respiration tends 
to prevent, in spite of gravitation, any accumula- 
tion in the air-tubes ; but the excretion is more 
completely effected by coughing and special eflTorts 
of expectoration. These consist of a quick and 
forcible expiration, preceded by a deep inspiration, 
and accompanied with a constriction of the larynx 
and trachea, the effect of which is to bring any 
superfluous matter into positions from which the 
air, forcibly expired, drives it through the glottis. 
It is worthy of remark that expectoration cannot 
effectually take place without a previous full in- 
spiration, by which air is carried beyond the accu- 
mulating matter ; hence, when this is prevented, 
either by weakness of the respiratory powers, or 
by the impermeability of the bronchial tubes, 
the excretion is suppressed. The first of these 
causes of obstructed expectoration is exemplified 
in adynamic fevers, which may thus prove fatal : 
the second occurs in pneumonia in the stage of 
hepatization, and, if extensive, must lead to a 
fatal obstruction of the respiratory function. They 
probably occur together towards the fatal termina- 
tion of bronchitis, phthisis, and other severe dis- 
eases of the lungs. 

Expectoration in its other sense, namely, the 
matter expectorated, is a subject well worthy of a 
careful study ; for its characters often furnish 
signs of the greatest value in the diagnosis, prog- 
nosis, and treatment of diseases of the chest. It 
can scarcely be said that the examination of the 
sputa is entirely neglected in this country ; but 
we have had frequent occasion to observe thai 
opinions are very loosely and vaguely formed 
from it, and of a nature quite inconsistent with 
the present state of pathological science. Thus 
the presence of pus in the expectoration is fre- 
quently looked upon as a sure proof that the lungs 
are " diseased ;" whilst the far more pathognomic 
sputa of peripneumony and the well-marked se- 
cretion of acute bronchitis are hardly recognized. 

The natural secretion of the bronchial mucous 
membrane is a colourless liquid of somewhat glu- 
tinous quality, like a thin solution of gum arabic. 
It does not greatly differ in chemical composition 
from the serum of the blood, and it owes its vis- 
cidity to an animal substance, which Dr. Pearson, 
(Phil. Trans. 1809,) Dr. Bostock, (Elementary 
System of Physiology, vol. ii.) and Berztliu.'' 
(Annals of Philosophy, vol. ii. p. 382) concur in 
considering an imperfectly coagulated albumen. 
This secretion is the basis of most of the varictiea 
of expectoration; but, unhappily, our knowledge 
of animal chemistry does not enable us to disco 
ver the precise nature of the changes in composi- 
tion which produce these varieties. All tl,\at we 



120 



EXPECTORATION. 



learn is that albumen, in different forms and pro- 
portions, is present ; for, whether the expectora- 
tion be mucus, serum, pus, tuberculous matter, 
or coagulated lymph, the chemist can discover in 
these but scarcely discernible varieties of this same 
principle. There seems to be a considerable va- 
riation in the proportion of saline matter in differ- 
ent kinds of expectoration ; and on this depends 
a distinction, formerly much insisted on, by means 
of the salt or sweet taste. This criterion certainly 
fails in distinguishing pus from mucus ; but we 
think that an excess of saline matter may be 
taken as a sign of inflammatory action in the mu- 
cous membrane. It is by its mechanical and visi- 
jle conditions, however, that expectorated matter 
is most distinctly characterized ; and to examine 
these fairly, the entire sputa should be collected 
in one oir more convenient vessels of white ware 
or glass, in which their quantity, colour, and con- 
sistence, can be minutely scrutinized. 

In acute bronchitis there is at first a diminution 
of the natural quantity of the bronchial mucus, 
with a sense of roughness and dryness in the 
larynx and trachea ; but soon a saltish liquid is 
secreted, which increases as the inflammation 
reaches its height. It is transparent, almost col- 
ourless, and moderately viscid, resembling raw 
white of egg diluted with water. It generally re- 
tains a good many air-bubbles within it, and if 
expectorated with much coughing, it is usually 
covered with a froth. When poured from one 
vessel into another, it falls in a stringy or ropy 
stream. Andral (Clinique Medicale, torn, ii.) con- 
siders that its viscidity is in proportion to the inten- 
sity of the inflammation ; an increased viscidity be- 
ing always accompanied with an aggravation of the 
fever, dyspnaja, and other symptoms. When the 
bronchitis is attended with fever, he remarks that the 
sputa become more viscid during the febrile exacer- 
bation ; insomuch that one inexperienced might be 
led to suppose that the inflammation had extended 
to the parenchyma of the lung: after the paroxysm, 
however, they return to their former state. At 
the height of the inflammation, and at other times 
when the cough is violent, they are sometimes 
streaked with blood : this is produced by the 
efforts of coughing, and does not tinge the whole 
mass. These characters are sufficient to distin- 
guish the expectoration of bronchitis in its first 
stages ; and as long as it remains in this state, 
there is no improvement of the symptoms ; but 
when the sputa become pearly or opake, or of a 
yellow or greenish-white appearance, we may be 
pretty confident that the inflammation is on the 
decline. This opacity is first perceived in the morn- 
ing expectoration, and in a few points only ; and 
it is uniformly accompanied with an amelioration 
of the symptoms. The evening exacerbation some- 
times brings back the glairy transparency of the 
secretion ; but, unless there be relapse, the opacity 
returns on the succeeding morning, and gradually 
extends to all the expectoration, which is then 
nearly opake, and greenish or yellowish white : 
the smoke and dust in the respired air sometimes 
communicate a grey or dirty tinge. This change 
is often remarkably conspicuous after the success- 
ful operation of a sudorific; and, in fact, free per- 
spiration will sometimes partially accomplish it 
•early in the disease. After the expectoration has 



thus become ripened or concocted, it is coughed 
up readily, and in loose distinct pellets, which, 
although glutinous in themselves, do not so read- 
ily unite into one mass as before ; they gradually 
diminish in quantitj^ and in a corresponding de- 
gree the cough and other symptoms cease : a re- 
lapse is equally marked by a return of the expec- 
toration to its glairy transparent state. Sometimes 
a cold is prolonged by a series of relapses ; and, 
notwithstanding the length of its duration, the 
sputa retaining the same character, the affection 
preserves its chronic form, and does not terminate 
until the same change has taken place. These 
successive transitions, which were noticed by Hip- 
pocrates and Aretaeus, are highly useful to the 
practitioner in discovering to him the state of the 
disease, and, taken with the pulse and physical 
symptoms, will safely guide him in the employ, 
ment of his remedies. 

The expectoration in chronic bronchitis is of a 
very diversified character, and is therefore much 
less certain in its indications. There is generally 
in it, opake, yellowish, or greenish-white mucus, 
like that expectorated at the termination of the 
acute disease ; but it is usually more difHuent, and 
often floats in a pituitous or serous liquid. The 
same mucus is sometimes voided in a more inspis- 
sated form. Andral describes it as resembling 
false membranes, and moulded into the shape of 
the bronchial ramifications ; and Dr. Cheyne (Pa- 
thology of the Membrane of the Larynx and 
Bronchia, p. 147,) and Laennec give accounts 
of a similar expectoration. In the milder cases 
the mucus thus modified constitutes the whole 
expectoration ; but in a severer form of the dis- 
ease purulent matter is added, and the appearance, 
consistence, and odour of the sputa present very 
great variety. 

Many tests have been devised to distinguish 
pus from mucus ; but from what we have before 
remarked on the close similarity of their chemical 
composition, it may be judged that they pass by 
insensible gradations into each other. [Nor docs 
the microscope exhibit any marked difference in 
physical character, structure, and apparent com- 
position between them. (Donne, Cuun dt Mi- 
croscopic, p. 177: Paris, 1844.)] The utility 
of minute distinctions of this sort may therefore 
well be questioned, as they neither enlighten us on 
the pathology, nor guide us in the practice. Pus 
IS much less viscid than mucus, and not retaining 
air-bubbles, as mucus does, it commonly sinks in 
water, whereas mucus generally floats at the sur- 
face ; and this test gives us as much as is useful 
in the distinction. When the two are mingled in 
various proportions, this and all other tests "fail in 
discriminating them. Proceeding from different 
parts of the bronchial membrane in different de- 
grees of inflammation or morbid affection, some 
portions of the expectoration are mucous and vis- 
cid, whilst others are purulent and diffluent ; some 
greemsh-white like pus ; others grey, dirty-look- 
ing brown, or tinged with blood : generally they 
arc inodorous, but sometimes they exhibit a re- 
markable fetidity. These characters, however 
varymg, are unquestionably diagnostic signs of 
chronic inflammation of the bronchial membrane; 
but their value in the prognosis and in practice is 
greatly diminished by the circumstance of such 



EXPECTORATION. 



121 



chronic inflammation being frequently complicated 
with other lesions. It almost always, for instance, 
accompanies the last stage of tubercular disease 
in the lungs, generally furnishing a great part of 
the matter expectorated ; and its existence is of 
small importance compared with the phthisical 
lesion. An inspection of the expectoration alone 
often fails to distinguish these combined cases 
from those of simple chronic bronchitis. In gen- 
eral, it may be said that purulent sputa indicate a 
severe form of disease ; but they neither necessa- 
rily imply phthisis, nor any other irremediable 
malady. The chronic bronchitis excited by ha- 
bitual inhalation of dust or powder, as among 
needle-pointers, leather-dressers, porcelain-makers, 
&c., is commonly attended early with purulent 
and bloody expectoration ; but if the cases are 
treated in time, and the patients are removed from 
the continued application of the exciting cause, 
they generally recover. So also, severe cases suc- 
ceeding to measles and scarlatina sometimes pre- 
sent purulent expectoration, yet they are far from 
being universally incurable. We repeat, there- 
fore, that puriform matter in the expectoration, as 
a prognostic sign, only indicates an aggravated 
form of disease. 

The nature of the expectoration gives the dis- 
tinctive characters to the diseases termed by Laen- 
nec dry and pituitous catarrh. The former is a 
kind of asthma, attended with no other expecto- 
ration than scanty pellets of very tough grey mu- 
cus, which lodge in the bifurcations of the bron- 
chi, and sometimes cause severe fits of asthma. 
It is important to recognize the expectoration of 
this disease, as it is singularly benefited by the 
alkaline treatment recommended by Laennec. Pi- 
tuitous catairh, or humoral asthma, is remarkable 
for the profuse watery expectoration which accom- 
panies its paroxysms. This discharge contains 
albumen, coagulable by heat, and seems to differ 
but little in nature from the serum of the blood. 
Its quantity is sometimes enormous, amounting to 
several pounds in weight. These two forms of 
secretion sometimes occur at the same time in dif- 
ferent portions of the bronchial membrane ; and 
the serous discharge, in smaller quantities, is a 
common accompaniment of chronic bronchitis. 

The expectoration of pneumonia is very char- 
acteristic. For the first two days there is seldom 
any expectoration ; but, about the third or fourth, 
a viscid transparent liquid is spit up, uniformly 
tinged with a rusty or orange hue. At first its 
viscosity is not so great but that it can be poured 
trom one vessel into another, and it falls in strings 
or ribands ; but in proportion as the inflammation 
reaches its height, and passes to the stage of he- 
patization, it becomes so glutinous that the vessel 
may be inverted, and even shaken without its falling. 
The red tinge is generally proportionably increased, 
but this is a less certain test than the viscidity, of the 
intensity of the inflammation. If the inflammation 
declines or is mitigated, the sputa become less vis- 
cid and rusty, until they present the characters of 
the expectoration in bronchitis. It is to be regret- 
ted that this valuable and truly distinctive sign 
does not show itself early and constantly in the 
disease. When it is present, it may confidently 
be depended on, but its absence by no me;ins dis- 
proves the existence of pneumonia. In some in- 
Vol. II 16 i, 



dividuals it never occurs ; and in children it is 
difficult to obtain a sight of the expectoration. It 
is also important to know that many adults, like 
children, invariably swallow the expectoration. 
The physical signs are, therefore, alone to be de- 
pended on in the diagnosis of negative cases. As 
a prognostic guide the sputa are highly instruc- 
tive. The unfavourable import of a late appear- 
ance of the sputa was noticed by Aretseus ; but 
M. Andral first pointed out the proportion which 
their viscidity bears to the intensity of the inflam- 
mation. As long as this goes on increasing, or 
remains undiminished, we may be sure that the 
inflammation is predominant; but if the expecto- 
ration shows a disposition to return to the colour- 
less and less viscid state of simple bronchitis, the 
disease may be known to be on the decline. In 
a few cases the expectoration increases in viscidity 
up to the hour of death, but more generally it is 
either suppressed or changed, particularly if the 
inflammation have proceeded to the stage of sup- 
puration. The suppression of the expectoration 
was considered by the ancients an unfavourable 
omen ; modern pathology discovers that it is so, 
either because it proves the inability of the patient 
to expel it, or because the secretion has ceased, 
and the inflammation passed to the hepalized and 
suppurated stages. In the former case suflTocation 
must soon ensue from the accumulation in the 
bronchi : in the latter the rusty exf)Cctoration is 
often replaced by other kinds. Sometimes it con- 
sists of brownish dirty-looking opaque mucus; 
sometimes whitish specks, as of pus, are seen in 
it, and, rarely, it is entirely purulent. 

M. Andral describes another kind of expecto- 
ration, which he considers generally to indicate 
the stage of suppuration. This is a deep reddish- 
brown and slightly viscid liquid, like the juice of 
preserved prunes or liquorice water. In six out 
of nine cases in which this was observed, the lung 
was found, on dissection, in the state of purulent 
infiltration ; in two it was hepatized ; the remain- 
ing case was a slight one, and recovered. Laen- 
nec does not attach any importance to this kind 
of expectoration, considering it ordy as the sign 
of a cachectic or scorbutic habit. It certainly 
cannot be considered distinctive, but it may be 
taken presumptively, and must generally be look- 
ed upon as an unfavourable sign. The tinge of 
the characteristic peripneumonic sputa, which is, 
in different instances, greenish-yellow, orange, 
rust-coloured, and bright-red, obviously proceeds 
from the colouring matter of the blood, intimately 
mixed with it in various proportions. If the in- 
flammation terminates in resolution, this tinge 
diminishes and disappears, and the sputa exhibit 
the characters, and go through the changes of the 
expectoration in bronchitis. 

In pure pleurisy there is either no expectora- 
tion, or one simply of a catarrhal nature. The fluid 
secreted in chronic pleurisy has been sometimes 
known to make its way into the bronchi, and to 
be evacuated by expectoration ; but other signs 
must rather be depended on for discovering the 
nature of such a case ; as a similar expectoration 
is sometimes derived firom a pulmonary abscess, 
and even from sudden and copious secretion from 
the bronchial lining only. 

The character of the sputa has been more con 



122 



EXPECTORATION. 



suited in the diagnosis of consumptive diseases 
than in any other; but the advances which have 
of late been made in developing the true nature 
of tubercular phthisis, have proved that all the 
distinctions and tests proposed are more or less 
fallacious. Thus it was long held that the pre- 
sence of pus in the expectoration was a pathogno- 
monic sign of pulmonary consumption ; and all 
efforts were directed to find out a sure method of 
detecting it and of distinguishing it from mucus. 
We have already remarked that purulent expecto- 
ration is not an uncommon consequence of simple 
bronchitis, and this disease presents all the phases 
formerly ascribed to phthisis. Something of the 
prognosis may, we believe, be learnt by consulting 
the expectoration, but its distinctive characters 
are to be depended on only after repeated exami- 
nations, and in combination with other signs, par- 
ticularly those of auscultation. 

In the first stage of phthisis, that of miliary tu- 
bercles, there is either no expectoration, and the 
cougli is dry, or it is of a simjde bronchitic nature. 
When the lungs are thickly studded with mihary 
tubercles, there is not unfrequctitly an abundant 
serous secretion like that of pituitous catarrh, 
which is accompanied with a constant and general 
mucous rhonchus in the lungs. Whenever these 
present themselves for any length of time in an 
individual of tuberculous diathesis, and especially 
if there be any irregularity of resonance on per- 
cussion about the clavicles, we consider the fate 
of the patient almost certain, and the disease will 
T)robably run a very rapid course. Except in this 
case, and in that of haemoptysis, which is treated 
elsewhere, (see Pulmonaut Apoplexy and H.e- 
■NOPTTsrs,) the expectoration does not assist us 
in the first stage of phthisis. 

The characters of the sputa in the second stage, 
or during the softening and evacuation of the tu- 
bercles, would be much more distinctive were they 
not alwaj's mixed up with the mucous and muco- 
purulent secretion of a chronic bronchitis, which 
always more or less prevails at this period. Hence 
the signs, as relating to the tubercular disease, 
must be considered in a corresponding degree am- 
biguous. Attentive examination will often dis- 
cover in the mucus expectorated fine whitish 
streaks, which consist of the softened tubercle ; 
more rarely there are little yellowish white masses 
like grains of boiled rice, which are portions of 
crude tubercle. As the softening proceeds and 
the cavities are enlarged, the sputa become less 
frothy, sink in water, and are principally compos- 
ed of greenish white masses of irregular shape and 
outline, sometimes tinged in parts of a dirty red 
or brownish colour. These flatten at the bottom 
of the vessel like a piece of money, whence they 
have sometimes been called nummulary sputa. 
In some rare instances small portions of the pul- 
monary tissue itself have been detected with the 
preceding. When the disease is further advanced, 
the expectoration assumes a brown, dirty green, 
or grey colour, and the sputa are frequently sur- 
rounded with an areola of a bloody tinge. It is 
exceedinglv difficult to say what degree of weight 
should be attached to these several appearances, 
even when they are unequivocally seen. It might 
be supposed that the presence of the whitish 
sfcuks 01 of (he little wliite masses would be con- 



clusive, as being themselves tubercular matter; 
but appearances of the same kind may present 
themselves from other sources. The minute 
bronchical ramifications, in chronic inflammation, 
sometimes secrete a purulent liquid, which may 
produce the same streaky appearance; and ver- 
micular concretions and filaments of yellowish 
white lymph formed in the same way may be 
mistaken for little fragments of tubercle. The 
little rice-like bodies, which were considered by 
Baglivi, and Bnyle, and even by Hippocrates, as 
indications of phthisis, are moreover closely simu- 
lated by certain sebaceous concretions formed in 
the tonsils, and, according to Andral, by similar 
productions from follicles in other parts of the 
pulmonary mucous membrane. The white mat- 
ter from the tonsils may, however, be always dis- 
tinguished, as Laennec has pointed out, by their 
fetid odour and by their greasing paper when 
heated ; and without attention to this test, the 
sign cannot be depended on. The globular yel- 
lowish white masses, like irregular balls of flock 
or wool, which apparently consist of pus held in 
shape by a little tenacious mucus, have been 
noticed by several writers as peculiar to phthisis. 
Dr. Forbes (Transl. of Laennec, 3d edit.) says 
that this kind of expectoration has appeared to 
him to be most common in young subjects of a 
strongly marked strumous habit, and in whom the 
disease was hereditary. A precisely similar ap- 
pearance is, however, sometimes presented by the 
sputa in chronic bronchitis. The dirty brown or 
green matter, flattening and becoming nummidary 
when separate, and when together forming a 
smooth sluggish purilage, which appears later in 
the disease, and takes its origin from the tubercu- 
lar excavations, is much more certainly character- 
istic of phthisis. To sum up, we may say that 
an occasional examination of the sputa, by far the 
greatest part of which, as Laennec has remarked, 
proceeds from an accompanying bronchitis rather 
than from the tubercular disease itself, can only 
enable us to distinguish phthisis in the very rare 
case of tubercular matter, or portions of the tissue 
of the lung being present : but with Dr. Forbes 
and M. Andral, we think that by a daily careful 
inspection of the expectoration, we. shall not fail 
to find in the successive and progressive changes 
which it presents, the means of forming a pretty 
accurate diagnosis, which, if confirmed by the ge- 
neral and physical signs, will leave no shadow of 
doubt. 

As our design in this article has been rather to 
direct the attention of the practitioner to the 
importance of expectoration as an aid in diagnosis 
and prognosis, than to give a complete account of 
the subject, we refer for further descriptions to the 
articles in which the diseases of the chest are par- 
ticularly treated of. 

In conclusion, we would strongly recommend 
our readers to consvdt the second and third 
volumes of Andral's Clinique Medicale, and Dr. 
Forbes's translation of Laennec's Auscultation 
Mediate, where they will find instructive and con- 
vincmg proof of the assistance which the expec- 
toration gives, especially if taken in conjunction 
with the physical signs, in the distinction and 
treatment of diseases of the chest. 

C. J. B. Williams. 



FAVUS— FEIGNED DISEASES. 



123 



[EYE, DISEASES OF THE. (See Amau- 
Bosis, Ophthalmia, &c.) 

FARCY. (See Glandehs.)] 

FAVUS. The pustules termed favi are so 
named from the character of the crusts by which 
they are succeeded ; these being cellular, and fan- 
cifully compared to an irregular Konty-comb. The 
term favus, however, was differently employed by 
the ancients : Galen apphed it to ulcers which 
exude, through small orifices, a matter resembling 
honey in consistence : Celsus regarded it as 
synonymous with miliary. Favi, in the modern 
acceptation of the word, are small, yellow, irregu- 
larly circular pustules, nearly flat — at least, not 
accuminated; and, according to Biett, always de- 
pressed in the centre. Their base is slightly in- 
flamed ; they generally appear in circular patches 
or clusters ; are atten-ded with itching, and fre- 
quently with glandular swellings from absorption 
of the matter. These pustules are succeeded, 
after some days, by a thick yellow, nearly semi- 
pellucid, somewhat cellular, augmenting crust or 
scab ; at which time they frequently exhale a 
very offensive, nauseating odour, not unlike that 
of the urine of a cat. As the crusts dry, they 
become white, and easily detached. 

The seat of favi is most commonly the scalp, in 
the epidermal layer which covers the papillae of 
the true skin. As they most commonly occur on 
parts covered with hairs. Dr. Duncan advanced an 
opinion that the disease is in the bulb of the hairs, 
which are indeed easily detached, and display a 
swelling at the base. Biett accords with this 
opinion ; but Rayer dissents from it, and sup- 
ports the view which we have adopted. 

Favi generally occur during childhood ; they 
seldom affect the general health, although, when 
they appear during the period of dentition, they 
seem to be in a great degree connected with the 
disordered state of the digestive organs which 
more or less attends that period, and the increased 
irritability of the habit. They occasionally, how- 
ever, appear in adults, on the neck, ears, and 
occiput : in these cases they are always preceded 
by some degree of constitutional derangement; 
headach, an uneasy state of stomach, loss of appe- 
tite, irregular bowels, and fever: the inflammation 
surrounding the pustules is more extensive, and 
the crusts are thicker and harder than in child- 
hood. Alibert affirms that cooks are very liable 
to eruptions of favi. They are chiefly known as 
the distinctive feature of one species of porrigo, — 
P. favosa; under the head of which we shall 
have again to direct the attention of our readers to 
their characters. Biett (Abrege pratique des 
Maladies de la Peau, par MM. Cazemene et 
Schedel, p. 231,) supposes that minute pustules 
of porrigo scutulata, which appear in circular 
patches, are favi, differing only in their arrange- 
ment and some little variation in the state of the 
crusts ; but as far as we are enabled to form an 
opinion by the appearances which they present, 
when viewed with a powerful magnifier, the 
opinion of Bateman, (Synopsis, edit. 7th, p. 138,) 
who regards them as achores, is coiTect. Rayer 
(Traite theorique et pratique des Maladies de la 
Peau, par P. Rayer, vol. i. p. 520,) considers both 
the pustules and crusts intrinsically different from 
those of porrigo favosa. 



As we shall have again to detail the treatment 
of favi under the article porrigo favosa, we have 
only to mention, at this time, that it consists iu 
correcting the irritable state of the stomach, and 
in not permitting crude undigested matters to 
remain in the alimentary canal. This is best 
effected by moderate doses of hydrargyrum cum 
creta, combined with antimonials, administered 
at bed-time ; and alkaline salts, particularly sub- 
carbonate of soda, in combination with calumba, 
or cascarilla, or cinchona bark in powder, given 
twice or three times a day. It was the opinion of 
^tius and other old writers, that danger attended 
the repulsion of favi: modern practitioners, re- 
gardless of this, employ a variety of external ap- 
plications ; but these are general mild stimulants, 
intended rather to restore the healthy action of 
the skin, after the crusts have been removed by 
poultices, than to repel. They consist of oint- 
ments composed with the oxides of zinc, acetate 
of lead, and tar with sulphur; and the ointment 
of nitrated mercury largely diluted with simple 
cerate. When there is much itching or pain, the 
writer of this article has seen great benefit derived 
from the following lotion, applied in a tepid statf*, 
in the form of a poultice. 

R. Liquoris plumbi subacetatis, f.^iss. 
Acidi hydrocyanici, f.^ii. 
Aqute destillatse, f-Jvi. M. Fiat lotio. 

Cleanliness, exercise in the open air, and the 
stimulus of soap and hot water, are great aids to 
every method of treatment. Much depends on 
diet, which should be apportioned both in quan- 
tity and quality to the powers of the stomach and 
the general strength of the patient. If the patient 
is weak, which is generally the case, the food 
should be nutritive, but not stimulant ; we have 
found nothing answer better than milk, with a 
moderate allowance of plainly cooked mutton or 
poultry once a day. Wines and all kinds of fer- 
mented liquor ai^ injurious. 

Favi appearing under the form of porrigo favosa 
are contagious ; and it is probable that they are 
equally so when they suddenly appear as sympto- 
matic of derangements of the stomach and chylo- 
poietic viscera; but we have seen no positive de- 
monstration of their contagious nature under these 
circumstances. ^_ -p_ THOMSON. 

FEIGNED DISEASES. It is our intention 
to notice under this head all that class of alleged 
corporeal disabilities which are either pretended or 
intentionally induced. In strictness of classifica- 
tion, cases of this kind should be arranged in four 
groups : — 

1. Feigned diseases, strictly so called, or those 
which are altogether fictitious. 

2. Exaggerated diseases, or those which, exist- 
ing in some degree or form, are pretended by the 
patient to exist in a greater degree or different 
form. 

3. Factitious diseases, or those which are 
wholly produced by the patient, or with his con- 
currence. 

4. Aggravated diseases, or those which, origi- 
nating in the first instance without the patient's 
concurrence, are intentionally increased by artifi 
cial means. 

It is not, however, our intention to adopt tn'. 



124 



FEIGNED DISEASES, 



classification in the present article. We shall 
arrange all the diseases under one head, and in 
alphabetical order ; this method being more sim- 
ple, more in accordance with the general plan of 
this work, and affording greater facilities for prac- 
tical reference. We may also here observe, that, 
for reasons of convenience, we shall apply the 
term feigned to all the varieties of these disa- 
bilities. 

The following are the classes of persons by 
7?hom diseases are chiefly feigned, and the causes 
tf their being so : — 

1. Men apprehensive of being levied, or actually 
iBvied, or forced into the military or naval ser- 
fice ; conscripts ; men liable to serve in or to be 
<lrafted for the militia ; impressed seamen. The 
cause of diseases being feigned by such persons 
is the hope of being deemed unfit for the duties 
of the public service, and thus to escape it altoge- 
ther. 

2. Soldiers, and seamen in the navy. The causes 
which induce these persons to feign disease are 
chiefly the following : 

a. To obtain their discharge from the service, 
with or without a pension. 

b. To avoid the performance of the duties im- 
posed on them ; to escape some particular service 
that is disagreeable to them, or to obtain some 
other that is agreeable ; to obtain a removal from 
one climate or station to another ; to obtain the 
ease and comfort of an hospital, &c. 

c. To avoid an apprehended or adjudged punish- 
ment. 

Soldiers and sailors feigning disease are com- 
monly designated as malingerers or skulkers. The 
latter term is exclusively used in the navy. 

3. Slaves. These unhappy persons feign dis- 
eases from many of the motives which influence 
the soldier and sailor, whose services are compul- 
sory ; only they do not seek for a permanent dis- 
charge from their labours, which they know to be 
impossible, except indeed by death. Their chief 
objects are to obtain relief from labour, and to 
enjoy the comparative comforts of the hospital. 

4. Persons who have subjected themselves to 
the control of the laws, and are either undergoing 
punishment or in apprehension of it; persons 
about to undergo a trial for some alleged offence, 
or about to be punished for the same ; prisoners 
for debt, or other offences, civil or criminal. The 
motives of such persons for feigning diseases are 
suflSciently obvious, viz. to evade or escape punish- 
ment or restraint. 

5. Persons in civil life who have received slight 
injuries, and who greatly exaggerate their degree 
or consequences. This is generally done with the 
view of extorting a disproportionate compensation 
from the party injuring. 

6. Persons in the lower ranks of life desirous 
of exciting the attention and compassion, and con- 
sequently the bounty of the public, or a mainte- 
nance in idleness. This class comprehends the 
•professed mendicant, whether vagrant or station- 
ary, whether gipsy or gentleman-beggar; and also 
persons in the lower ranks among the poor, who 
occasionally in this manner practise on their richer 
neighbours. Under this class, also, come persons 
in the lower ranks of life who wish to obtain relief 
from benetit societies, or from the narochial funds, 



or to gain admittance into or to remain in work- 
houses, hospitals, &c. 

7. Persons not at all in poverty nor living in a 
constrained position, who assume the semblance 
of disease from some inexplicable causes. These 
are chiefly females ; but the class is, on the whole, 
very small. 

We might add to these, other classes from va- 
rious conditions of life, from the boy " creeping 
like snail unwillingly to school," up to kings, 
warriors, statesmen, and various others in high 
stations, whom history records as having assumed 
sickness to gain particular objects ;* but the above, 
we believe, contain nearly all the cases that are 
likely to come under the notice of the medical 
practitioner. 

Some diseases or disabilities are much more 
easily feigned than others, and the imi)osture is 
more diflficult to detect. In those diseases of 
which the symptoms are naturally obscure, or va- 
riable and uncertain, much care should be taken 
not to come to a wrong conclusion. Every medi- 
cal practitioner knows that there are some diseases 
which are not indicated by a change of the pulse, 
an alteration of the natural colour or temperature 
of the body, or by any evident derangement of its 
functions. Tiiere are also other diseases the symp- 
toms of which are capable of being imitated by 
the effects produced by certain drugs, or by the 
use of certain external applications, &c. An in- 
timate knowledge of the anatomy, physiology, and 
pathology of the human body, and of tlie effects 
of the articles of the Materia Medica, is therefore 
essential to enable the medical practitioner to ob- 
viate false conclusions and detect imposture in 
such cases. 

When a medical practitioner is called upon to 
examine, for the purpose of legal investigation, or 
to treat a doubtful case of disease, he should en- 
deavour to obtain all the information he can re- 
specting the person's moral and physical habits, 



* Many great names, illustrative of the statement in 
the text, might be mentioned. The plan adopted by 
Ulysses to avoid leaving his young bride for the war of 
Troy, is fnmiliar to the classical rftader. The particular 
manner in which this royal malingerer chose tu exhibit 
his alleged infirmity, and the mode of its detection, are 
pleasing illustrations of the rude simplicity of early 
times. The king goes as usual to his agricultural labours, 
but not as usual like a sober ploughman ; ho yokes toge- 
ther in the same plough a horse and an ox, and sows his 
field with salt in place of corn. With the view of putting 
to the test his alleged disease, Palaminles places Tele- 
machus in the furrow b(!fore the father, who betrays bis 
sanity by carefully avoiding the infant. The liistory of 
the feigned insanity or idiocy of the older Brutus is 
equally well known; as is that of Ariiiion the son of 
David, who "made himself sick" for a more guilty pur- 
pose. Charles, Uuke of Bourbon, constable of France, 
wishing to desert to the emperor, " feigned sickness in 
order to have a pretence for staying behind." — (Hume.) 
In like manner, 

; ;: " Hotspur's father, old Northumberland, 

Lay crafiy-sick," 

to avoid the battle of Shrewsbury. Essex the favourite 
of Elizabeth, is said to have feigned a violent disease to 
move her compassion; and Raleigh pretended "mad- 
ness, sickness, and a variety of diseases, to protract his 
examination and procure his escape." (Hume's .Tames I.) 
Pope J.ilius III. feigned sickness, to avoid the holding 
of a cousi.^itory ; and, that he might give the deceit the 
greater colour of probability, he not only eonfiued him- 
self to his apartment, but changed his usual diet and 
manner of life." By persisting in this plan, however he 
contracted a real disease, of which he died in a few 
days.-(Robertson's Charles V.) it wo |,| « ea "v to ad^ 
greatly to the above list, from the storesof radit on and 
authentic history, ancient and modern. "^^"'"°" »'*<" 



FEIGNED DISEASES. 



125 



his probable motives, &c. &c. ; and he should also 
consider whether the alleged causes of disease are 
founded in fact, or are probable. Another impor- 
tant point is, to endeavour to ascertain whether 
the pathognomonic symptoms of the alleged dis- 
ease are present. " It is obvious," says Dr. 
Cheync, " that the more we know of disease by 
reading and observation, the more patience and 
temper we possess, the more successful shall we 
be in the detection of imposture. I am convinced 
that simulated disease will soonest be discovered 
by those who conduct the inquiry in the most sci- 
entific manner, carefully applying the case in doubt 
to the description of the disease in standard works 
of pathology." (Letter to Dr. Renny, on Feigned 
Diseases ; Dublin Hospital Reports, vol. iv.) 

It is difficult for the simulator of a disease to 
give a consistent account of the origin and pro- 
gress of his alleged infirmity. By a little manage- 
ment on the part of a medical practitioner, an im- 
postor will almost always be led to enumerate 
incompatible symptoms, or greatly to exaggerate 
unimportant lesions. He is constantly prone to 
overact his part. He is too anxious to impress 
upon the medical attendant the reality and the se- 
verity of his sullerings. Remarks are thrown in 
purposely to obviate objections, and to reconcile 
the mind to what may seem extraordinary in the 
narrative ; all of which are very unlike the bold 
simplicity of truth. 

With the view of inducing a detected or even 
suspected impostor to acknowledge his deceit, se- 
vere measures, such as the infliction of pain, &c. 
remedial agents, and even formal corporal punish- 
ment, have been occasionally adopted. This prac- 
tice, however, if it were justifiable, will be fre- 
quently found to fail even in the army or navy, 
where patients are under the control of strict dis- 
cipline. But it ought to be a general rule that 
means should never be adopted in the treatment 
of a doubtful case, which we should regret having 
employed if the alleged disease were to prove 
genuine. Soldiers and sailors commonly return to 
their duty when they are deprived of all hope of 
succeeding in a scheme of imposture ; and finesse 
will often succeed in detecting imposture, where 
harsh measures would completely fail. Dr. Da- 
vies, surgeon to the East India Company's depot 
at Chatham, had a soldier under his care with an 
alleged afiection of the back, which, the man as- 
serted, rendered him unable to move or be moved 
from his bed. His alleged disability had existed 
for about a month, without any indication that he 
intended to return to his duty. For the con- 
venience of being watched, &c. he had been ac- 
commodated in a ward by himself. Dr. Davies, 
who considered him to be an impostor, saw no 
prospect of his giving in ; but he eventually put 
in practice a measure which led to detection. He 
went to the window of the ward in the dusk of 
the evening, and, after gently tapping upon the 
glass, he in a low voice called the man by his 
name. He was at the window in an instant, and 
Dr. Davies had the pleasure of congratulating him 
on the recovery of the power of locomotion. The 
man forthwith went to his duty. 

Sometimes impostures are discovered entirely 
by accident, even when they are not at all sus- 
pected to exist. The following is a curious in- 



stance of this kind. A seaman on board H. M. 
ship Otter feigned a chronic decline so effectually, 
that he not only deceived his surgeon, but the phy- 
sician of the Naval Hospital to which he was 
sent ; and he was about to be discharged from the 
service, when the true nature of his case was elu- 
cidated in an unexpected manner. The mail 
from the sea-port where the man was in hospital 
was robbed, and the letters were broken open with 
the view of searching for money. The robbers 
were, however, taken, and the letters recovered. 
Among the opened letters was one from the man 
in the hospital to his wife, wherein he informed 
her that his scheme had succeeded, that he was 
going to be invalided on a certain day, and desir- 
ing her to make good cheer against his arrival. 
This letter was forwarded to Capt. W., and, in 
consequence of its contents, the man, although 
seemingly in almost a dying state, was returned 
to his ship. The letter being read to him, and 
his hopes thus destroyed, he at once returned to 
his duty. 

It is frequently useful to depart from the usual 
mode of examining doubtful cases ; preconcerted 
plans being thereby disconcerted, and an impostor 
puzzled. One of the writers of this article was 
requested to look at an old soldier who had been 
long in a civil hospital on account of an alleged 
contraction of the left knee, the real existence of 
disease being doubtful. The examiner went to 
the left side of the bed upon which the man was 
lying, and after looking at the contracted knee he 
desired the man to lie upon his face, by which 
change the right extremity assumed the place of 
the left in the bed. The examiner's hand was 
then placed upon the right knee, which became 
gradually flexed, while the contraction of the left 
knee disappeared. This man's attention was so 
completely engaged with the right knee when it 
was under examination, that he forgot that it 
was his left knee which he had alleged to be con- 
tracted. 

It might be an amusing subject of inquiry how 
particular diseases come to be assumed in prefer- 
ence to others. Our limits will not permit us to 
enter upon this investigation. A principal, if not 
the chief cause, is the relative facility with which 
diseases may be feigned or formed ; some, as we 
have already observed, being much more easily 
assumed than others. Imitation of the real dis- 
eases which the impostors are in the habit of see- 
ing is also at once a frequent source of their know- 
ledge, and the exciting cause of their putting it to 
account. We have thus known soldiers and sailors 
carefully study and mimic numerous ailments of 
their comrades. We remember the case of a sol- 
dier who imitated admirably and successfully the 
gait of a patient with hip-disease, which he had 
studied from the life in a boy who actually laboured 
under that affection. 

We know not that any excuse is necessary for 
the extent of the consideration which we purpose 
to give to the subject of the present article. Cer- 
tainly none will be expected by those of our read- 
ers who either now practise, or formerly have 
practised, in the medical departments of the army 
or navy, who are fully aware of its great impor- 
tance. If there oe any practitioner in civil life 
who entertains doubts on this point, the facts i« 



126 



FEIGNED DISEASES, 



tailed in the present article will, we think, be found 
more than sufficient to remove them. And al- 
though it is especially in the practice of the medi- 
cal officers in the public service that cases of 
feigned diseases occur, yet their occurrence in pri- 
vate practice, particularly among the patients of 
our hospitals and dispensaries, is by no means 
extremely rare ; and many of them are of such a 
kind as to expose the knowledge or ignorance of 
the physician or surgeon more positively and more 
conspicuously than any other cases. Many of 
them, also, become the subjects of legal investiga- 
tion, and require medical testimony to be given in 
courts of law. 

In the army and navy it is the duty of the 
medical officers to protect the public service from 
impositions of this kind ; and it is well known to 
those officers who served during the late prolonged 
wars, how seriously the service both of the army 
and navy suffered from such impostures being 
oftentimes successful. On the decision of the 
medical practitioner as to the true character of 
doubtful cases, very frequently depends the acquit- 
tal or punishment of the alleged invalid ; and 
every one must feel the responsibility of such a 
position. It is well known to those who have had 
opportunities of judging, that men in the army 
and navy, more particularly the latter, have been 
often treated and punished as impostors, who were 
really labouring under disease ; and also that real 
impostors have often received the immunities and 
privileges that ought to belong only to the diseased. 
The scene in Roderick Random, of the captain 
and doctor curtailing the long sick-list, is probably 
only a slight exaggeration of what Smollett may 
himself have witnessed in the olden time of the 
navy ; and although no such scene could be ex- 
hibited now-a-days, it must be allowed that nothing 
but that firmness of purpose which can alone be 
founded on the knowledge of disease, will always 
enable the medical officers in that department of 
the public service to protect the rights of humanity 
and the dignity of the profession of medicine. 

1. Abdominal Tumoiir> — (^Ascites, tympa- 
nites, physconia.^ — Various affections of the abdo- 
men characterized by external swelling are often 
both feigned and formed by persons desirous of 
obtaining certain objects under the cloak of dis- 
ease. Wc have seen dropsy simulated for some 
time successfully, merely by the individual push- 
ing the abdomen forward while in the erect posi- 
tion, and elevating the spine when lying on the 
back ; probably, at the same time, keeping up the 
distension by means of very short expirations. A 
complete exploration of the uncovered abdomen 
will always detect imposition of this kind. It has 
been proposed in such cases to observe the patient 
when asleep : but such simulators are sometimes 
prepared for this test, and wrap themselves up so 
completely in the bed-clothes that the end cannot 
■;« obtained without awaking them. 

A more effectual mode of deceiving is, to dis- 
tend the abdomen by the introduction of foreign 
substances. Instances are said to have occurred 
among the French conscripts where water was 
actually injected into the cavity of the peritoneum, 
and a true factitious ascites thereby produced. 
r<)dere mentions the case of a woman who pro- 



duced a simulated ascites by inflating the cellular 
substance of the abdominal parictcs' with air, 
through a small and scarcely perceptible puncture 
in the groin. (Medecine Legale, tom. ii. p. 485.) 
Manual examination or palpation would immedi- 
ately detect this kind of deception. Tympanitic 
distension of the abdomen by artificial means has 
been more extensively and more successfully prac- 
tised. MM. Percy and Laurent mention the case 
of a young soldier who had the power of distend- 
ing his abdomen enormously by swallowing air. 
Presenting himself in this state, with clothes made 
for the occasion, he had no difficulty in obtaining 
his discharge. He got rid of his tympany at will, 
" par le moyen d'eructalions druyantes et non iti- 
terrompues, par haut et par bas." (Diet, des So. 
Med. t. xli. p. 328.) The following extract from 
Dr. fcheyne's excellent paper on feigned diseases, 
in the fourth volume of the Dublin Hospital Re- 
ports, will show the extent to which this mode of 
deception is sometimes carried. " In the year 
1811, from thirty to forty men of the 84th regi- 
ment were admitted into the King's Infirmary, 
labouring, as stated on the admission-ticket, under 
dropsy and intermittent fever. The abdomen was 
greatly distended and felt tympanitic; the tongue, 
with few exceptions, was clean ; pulse regular ; 
urine natural, and bowels in general costive. The 
men complained of pain in the right side, and 
many of them of pain over the whole abdomen, 
with excessive thirst, drinking more than a gallon 
of water daily. The disease was at first consi- 
dered a consequence of the Walcheren fever ; but, 
from the numbers increasing, and all with the 
same symptoms. Dr. Harvey was led to conclude 
that the complaint was feigned. Under that im- 
pression he prescribed a solution of Glauber salts 
in weak tobacco-water, which he called the infu- 
sum beiiedidum ,- a cupful of this detestable com- 
pound was given in the morning, and repeated 
every fourth hour till it operated, and with perfect 
success ; all who were in the hospital recovered 
speedily, and the disease, which was becoming 
epidemical, soon disappeared ; however, sixteen 
had succeeded in obtaining their discharge before 
this method of treatment was discovered." It was 
reported that the men produced this artificial tym- 
pany by swallowing large quantities of chalk and 
vinegar. Is this probable ? 

Simulated dropsy, or other abdominal tumour, 
is a common deception of mendicants, and is by 
them usually accomplished by the aid of cushions 
fitted to the belly. A remarkable case of this 
kind is related in the Act. Nat. Cur., of a woman 
who practised this imposition for forty years, and 
made a comfortable livelihood by it. No tumour 
was found on examining the body after death; 
but a pad found in her wardrobe, weighing nine- 
teen pounds, and fitted to the shape of the abdo- 
men, explained the case. A man not long since 
obtained his living in Edinburgh by the same 
means ; on being detected he enlisted as a soldier. 

2. Aljstineiice, Partial or Total. — Absti- 
nence for a great length of time is sometimes feigned 
in order to excite public curiosity, and, consequently, 
commiseration and charity. Abstinence beyond 
a moderate period is contrary to the usual course 
of nature, and therefore strong suspicion may al- 
ways be entertained when extraordinary fasting is 



FEIGNED DISEASES. 



127 



alleged. The most noted imposture of this kind I 
in recent times is that of Ann Moore, the fasting 
woman of Tutbury. According to her own ac- 
count she fasted from March, 1807, for a period 
of six years. She certainly fasted for nine days 
and nights. (Edin. Med. Journ. vol. v.) For 
numerous references to similar cases the reader is 
referred to the Litteratura Medica of Ploucquet, 
art. Inedin. 

3. Animals in tlie Stomacli« — Mendicants 
occasionally allege that they have an animal in their 
stomach. There was a man not long since in 
Edinburgh, who was remarkably successful in 
deceiving the public by pretending that he had 
such an inmate, which he said occasionally came 
to his throat, a statement he attempted to corro- 
borate by making the most frightful grimaces. It 
may be mentioned, as in some degree illustrative 
of the means of deception in such cases, that one 
of the writers of this article has now under his 
care a patient affected with partial obstruction of 
the pylorus, who has the power of producing the 
most extraordinary noises in his stomach by 
throwing the abdominal muscles into strong ac- 
tion. The stomach is no doubt enlarged, and as 
it generally contains an immense quantity of liquid 
and also much air, the sounds are occasioned by 
the rapid commixture of these fluids of unequal 
density. There is a case recorded in the 9th vo- 
lume of the Edinburgh Medical Journal, which is 
remarkable, inasmuch as Dr. Spence, the reporter, 
details the circumstances as gravely as if he had 
no doubt of the fact. A woman, twenty-one years 
of age, having been indisposed for a few days, took 
some cathartic medicine, and passed by stool " a 
reptile of the lacerta species." The animal, of 
which a particular description is given, on the 
sole authority of the patient, is stated to have been 
between four and five inches long, and consider- 
ably thicker than a finger. 

4. Bliiitlnessj Total or Partial^ — This dis- 
ease is frequently feigned by wandering beggars, 
and also by men in the military and naval ser- 
vices. The most common form of assumed blind- 
ness is amaurosis ; but at other times paralysis of 
the eye-lids, producing blindness by preventing 
the access of light, is the alleged disability, and 
in this case an artificial ophthalmia is often induced 
at the same time. In feigned amaurosis, if the 
simulator is skilful and courageous, the deceit is 
with the more difficulty detected, because in true 
amaurosis there is sometimes a certain degree of 
motion in the iris. A remarkable case of pre- 
tended blindness is related by Mahon, in which 
the patient was placed on the steep bank of a river, 
and desired to walk forward. He unhesitatingly 
did so, and fell into the stream. This test was 
considered as a proof of the reality of the disease; 
but he was afterwards induced, on a promise of 
being discharged the service, to confess that the 
disease was feigned. (Med. Legale, torn. i. p. 366.) 
In this case the pupil contracted perfectly ; and 
although this may be no certain proof of soundness 
of the organ, it is perhaps fair to admit immobility 
of the iris on exposure to light as a sign of disease. 
In the following case the deception was equally 
complete, but the detection came from a different 
quarter. A seaman on board the Utile frigate, 
pretending to be totally blind, and believed to be 



so, was on one occasion permitted to go on shore, 
and was attended by a man to lead him about the 
streets. These two happened to quarrel, and even 
came to blows, when the blind man finding, as 
might be expected, that he was likely to have the 
worst of the fray, suddenly regained the use of 
his sight, and soon got the upper hand of his as- 
tonished guide. The latter being worsted, took to 
flight, was pursued through a great part of the 
town by his former protege, and, finally, received 
a severe beating from him. Next day the im- 
postor was severely flogged, and never afterwards 
exhibited any deficiency of vision. 

Blindness under the form of amaurosis used to 
be simulated to a great extent by the conscripts 
for the French army, and for some time with the 
desired effect. A dilated pupil and an inactive 
iris, the leading symptoms of this disease, may be 
induced by the extract of belladonna, the sub- 
stance supposed to have been employed. When 
a sufficient length of time is permitted, the means 
of detecting this fictitious amaurosis are obvious. 
It has been stated by good authority that two hun- 
dred conscripts were exempted from serving in the 
army by using belladonna. 

Intermittent blindness (nyctalopia, hemera- 
lopia) is much more frequently and successfully 
feigned by soldiers and sailors, more especially in 
warm climates, where the real disease is of very 
frequent occurrence. In tropical countries night- 
blindness occasionally prevails among Europeans 
epidemically, and hence arise at once the source 
of the imposture and the difficulty of detecting it. 
Night-blindness is a common disease in Egypt, 
and was frequently feigned by our soldiers in the 
expedition under Abercrombie. " Of some corps," 
says Dr. Cheyne, " nearly one-half of the men 
were affected with this complaint, or pretended to 
be so, for which, however, a remedy was soon 
found. In the parties engaged in the works, a 
blind man was joined to and followed one who 
could see, in carrying the baskets filled with earth; 
and when the sentries were doubled, a blind and 
a seeing man were put together, and not without 
advantage, as during the night hearing upon an 
outpost is often of more importance than sight." 
(Loc. cit. p. 146.) In tropical climates sailors 
frequently feign this disease with the view of es- 
caping night-duty. It is hardly possible to detect 
the imposition by mere symptoms, as in the real 
disease the aspect and functions of the eye are 
perfectly natural in full light. 

5. Cacliexia^ malacia^ or pica Africaiiorunia 
(Mai d'estomac, dirt-eating.) — This is a disease 
which often produces the most extensive ravages 
among the slaves in the West-Indies, carrying 
them off slowly, but with the certainty of a pesti- 
lence. It is not nearly so common now as for- 
merly, negroes being much more valuable to their 
masters, and better treated. It is often a real dis- 
ease, but it is often, also, a practice voluntarily 
adopted by the unhappy beings who are the sub- 
jects of it, with the object and with the effect of 
producing death. Still more frequently, perhaps, 
it is a mixture of real and factitious disease, thw 
primary disorder of the stomach prompting to the 
ingestion of crude substances, and thus giving the 
particular direction to the suicidal propensity 
Whether it exists as an irresistible propensity, or 



128 



FEIGNED DISEASES. 



is adopted as a means of producing disease, the 
practice of dirt-eating is always done in secret, and 
is invariably denied. All kinds of earth are eaten 
indiscriminately, such as the common soil or 
mould, and the plaster of houses, &c. The dis- 
ease produced is truly a cachexia, marked by dis- 
orders of various functions, diminution of the co- 
louring matter of the blood, &c. and terminating 
in general dropsy. The patients first complain 
of pain of stomach (hence its French name), then 
breatlilessness, and inordinate pulsation in the 
heart and large arteries, particularly of the carotids 
and aorta, on motion. They become bloated, their 
nails and the palms of their hands becoming white, 
and their lips, gums, tongue, &c., quite pallid. 
These symptoms continuing, anasarca follows, and 
death, in the great majority of cases, closes the 
scene. When the practice is carried to a great 
extent, it may be discovered by examining the 
stools, which will be found to consist in a great 
measure of the earth swallowed. Emetics are 
also administered for the same purpose, and the 
ejected matters being washed, the earth will be 
found to subside. (Dancer's Jamaica Practice of 
Physic.) 

Various means have been adopted to prevent 
this practice, and, among others, the affixing to 
the face an apparatus to prevent eating altogether 
except in the presence of the overseers ; but all 
are found of no avail while the insignia of slavery 
are on their bodies, and the hope of freedom in 
another life is in their hearts. " Negroes," says 
Dr. Williamson, " anticipate that they will, upon 
death removing them from that country, be re- 
stored to their native land, and enjoy their friends' 
society in a future state." And upon this, the 
last consolation of those wretched beings, one of 
the means of checking the suicidal epidemic is 
founded. The negroes imagine that if decapita- 
tion is performed after death, the transition to their 
native country is prevented, and hence has been 
exhibited the horrid spectacle of the heads of the 
dead negroes placed in some conspicuous situa- 
tion before their fellows. (Williamson's Med. 
and Miscell. Obs. on the West Indies, vol. i. p. 93.) 

6. Catalepsy* — This disease has often been 
feigned, sometimes in its characteristic form, but 
more commonly in some of its imperfect varieties. 
We have nothing to add to the notice of this simu- 
lated affection in the article Catalf.pst in this 
work. 

7. Circulation, disorders of the*— Disease 
of the Heart. — In the French army, during the 
rigid operation of the conscription, almost every 
severe disease was simulated with the view of ob- 
taining exemption from service, and many were 
adopted by the conscripts, the simulation of 
which must have been suggested by persons well 
acquainted with disease. The authors of the arti- 
cle on simulated diseases in the Dictionnaire des 
Sciences Medicales mention two cases which were 
intended to pass, and very nearly did pass, for 
aneurism of the heart or great vessels. In one of 
these a ligature was found tightly bound round 
the neck, and another round the top of each arm. 
On removing the ligatures, the purple and swollen 
state of the countenance disappeared, so that the 
man did not look like the same person, and the 
disordered action of the heart ceased. In the other 



case, a very fine ligature was so tightly bound 
round the neck as to be almost hid by the foKIs of 
the skin. This young man announced himself as 
affected with organic disease of the heart, and his 
terribly swollen and livid face certainly gave cre- 
dibility to his statement. 

It would appear from the testimony of several 
writers on the complaints of soldiers and sailors, 
that these persons are in possession of means of 
great power to derange the functions of the heart, 
and thereby to simulate and even to produce 
disease of that organ. Dr. Cheyne is convinced 
that many soldiers have the power of quickening 
their pulses and giving -violence to the heart's 
action, and states that he has frequently found a 
soldier's pulse, at the time of an expected visit, 
one hundred and twenty, or one hundred and 
thirty, and the same reduced thirty or forty beats 
within a quarter of an hour upon his repeating 
his visit unexpectedly. (Loc. cit. p. 165.) Seamen 
are said to produce such a temporary quickness of 
pulse by striking the elbow forcibly against abeam 
of wood, and this state they quaintly term the elbow- 
fever. More or less permanent derangement of the 
circulation is produced by the internal use of tobac- 
co, digitalis, tartar emetic, &c.; and it is well known 
to all old medical officers in the army and navy 
that these means are familiar to the skulkers and 
malingerers of the two services. A much more 
effective means of deranging the circulation, and, 
indeed, many other functions, is afforded by white 
hellebore taken internally ; and it appears from a 
paper of Dr. Quarrier, published by Mr. Hutchin- 
son, that it has been extensively used in the army 
for this purpose. The practice was introduced 
into the regiment of marine artillery by a man 
who had formerly lived with a veterinary surgeon. 
This man not only produced the disorder in him- 
self, but sold his secret and his drugs to many 
others. When a sudden and decisive result was 
sought for, as much as a drachm of the hellebore 
was administered ; but for the more slow and pro- 
gressive mode of deception, a small dose, such as 
from four to ten grains daily, was prescribed. The 
larger dose usually occasioned vomiting, purging, 
syncope, tremors, and great nervous irritability, 
which were followed by great and inordinate action 
of the heart and arteries, and this was in its turn 
succeeded by great debility, and sometimes by a 
disposition to paralysis. By the smaller dose, the 
stomach after a short time became completely dis- 
ordered, and much nervous irritability and conse- 
quent derangement of the circulation ensued. — 
Various other symptoms were observed in conse- 
quence of this poison, and in some cases a fatal 
result was very nearly induced, and would have 
been so in many cases, Dr. Quarrier thinks, had 
not the medicine fortunately been adulterated. 
Many men succeeded by these means in obtaining 
their discharge from the service. (Hutchinson's 
Pract. Observations in Surgery. Second edition, 
p. 149.) 

8. Contraction of the liimbs producing 
I.amcness.— This disability is often feicned by 
soldiers and sailors, and very frequently by mendi- 
cants and persons who wish to escape the punish- 
ment of " hard labour." A convict who was 
confined on board the Retribution hulk at Wool- 
wich, during the period of his sentence, which 



FEIGNED DISEASES. 



129 



was seven years, kept his right knee bent so as 
not to touch the ground with his foot all that 
time ; and he was on that account not set to 
hard labour with the other convicts. He was 
commonly employed in executing light jobs, which 
he could do in a sitting posture. When he moved 
from place to place, he used to hop upon the left 
foot with the assistance of a stick. At the end of 
the seven years he was discharged, and upon going 
away he very coolly observed, " I will try to put 
down my leg, it may be of use to me now. " He 
did so, and walked off with a firm step without 
his stick, which he had previously thrown away. 

Mr. Hutchinson considers this imposture as that 
which is most common in the navy next to ulcer, 
and relates some curious cases. A young seaman 
fell from the yard-arm into the sea, and pretending, 
when taken up, that he had struck his loins on the 
ship's anchor during his fall, and had thereby 
broken his back, he was sent to Deal Hospital. 
No external evidence of injury could be discovered, 
but he obstinately persisted in his story, and in 
proof of the alleged fact, he constantly kept his 
trunk bent at nearly right angles with the lower 
extremities. When a rug was placed on the floor, 
and he was laid upon his back upon it, his legs 
and thighs were kept erect in the air ; and when 
these were pressed down forcibly, he rose sudden- 
ly to a sitting posture, as if his hip-joints were 
anchylosed. He persevered in his deception for 
some time, but was soon after detected in the act 
of deserting from the hospital, running lustily for 
his liberty. A sailor on board the Druid pretended 
that his arm was contracted, and so immovable 
was the elbow.joint that the ulna and humerus 
had the appearance of being anchylosed. From 
long want of use, the muscles were wasted. The 
man had been for a long time excused from duty 
for the su|)posed disease. Mr. Hutchinson detected 
the imposture by a stratagem. Being brought up 
to be punished, and while eagerly engaged in con- 
versation with the captain, his attention was with- 
drawn from the limb, and Mr. Hutchinson, who 
had hold of it, suddenly straightened it without 
the least effort, in the presence of the whole crew. 
The man was punished, and immediately returned 
to his duty with the perfect use of his limb. (Loc. 
cit.) 

The following cases have come to our own 
knowledge. In a line of battle ship, an excellent 
seaman, and a favourite with his officers, suddenly 
withdrew from his duty, alleging that he had been 
seized with a violent pain in the loins which pre- 
vented him from assuming any other than a bent 
position. He was long treated as a real sufferer, 
and every kind of application (many very severe) 
was used for his recovery, but in vain. After a 
period of many months, the surgeon was super- 
seded by another, who soon began to entertain 
suspicions of the reality of the disease, and made 
every effort, both by severe treatment and watch- 
ing, to detect him. But, by day and night, asleep 
or awake, the patient still retained the same posi- 
tion. At length, however, this accomplished dis- 
sembler, like the pretended blind-man formerly 
mentioned, was betrayed by the violence of his 
own passions. One day, being accused by a mess- 
mate of. skulking, he was so incensed that he 
started up erect, and with all his power inflicted a 
Vol. II.— 17 



severe chastisement on his accuser. He now con- 
fessed his deceit, and alleged as the cause of it the 
unjust and injurious conduct of one of his officers. 

A seaman on board the Heron sloop pretended 
that he had lost, in a great measure, the use of his 
lower extremities, which were contracted ; and he 
was for a long time carried by his messmates from 
one part of the ship to another. He was at length 
sent to the hospital at Barbadoes to be surveyed, 
and being declared an impostor, was ordered to be 
taken on board his own ship to be punished. On 
his way from the hospital, however, being made 
aware of what was waiting him on board, he sud- 
denly started up in the cart, and leaped into a 
field of sugar-cane, and, although pursued by his 
attendants, succeeded in making his escape. 

During the late war, a seaman was received 
into Gibraltar Hospital on account of a fractured 
leg. When this was nearly cured, he began to 
pretend that the ankle-joint was contracted and the 
foot turned inwards. This position he obstinately 
maintained for twelve months, in spite of every 
effort to restore the limb to its proper position, and 
in defiance of the harshest treatment. One night, 
however, he contrived to get intoxicated, and the 
surgeon having occasion to visit his ward during 
the night, found him lying perfectly naked on his 
bed, and his ankle quite straight. He was imme- 
diately returned to his ship as an impostor, was 
punished, and exhibited no longer any contraction 
of his ankle. 

While transcribing this for the press, a flag- 
officer of the navy informed the writer that he was 
once member of a court of officers who invalided 
a seaman on account of a contracted knee-joint, 
which had resisted all kinds of treatment for a 
long period. On the day after he was discharged, 
he was seen walking upright by this officer in the 
town of Sheerness, and, being pursued, made his 
escape by a most nimble and active use of his legs. 

One mode employed for detecting these pre- 
tended contractions is to place a tourniquet on the 
limb above the joint, by which the muscles are 
prevented from acting, and the joint becomes in 
consequence movable. In cases of marked im- 
position of this kind, the naval surgeon has some- 
times transferred his patient to the captain. In 
cases of stiff knee-joint, the practice adopted by 
one disciplinarian was to cause the skulker to be 
lashed on the back, with small cords, by the boys, 
until he could run away from them. Of course 
no surgeon would give his sanction to such treat- 
ment. 

9. Deafiiesst — Loss of hearing is not unfre- 
quently feigned in the army and navy, and also 
by persons in civil life who wish to escape a pub- 
lic trial or to excite commiseration. Simulated 
deafness is, in general, alleged to come on rapidly, 
whereas the real disability takes place very gradu- 
ally. Two recruits complained that they had 
been suddenly attacked with deafness without any 
previous illness. The state of the meatus was 
natural, and no sign of inflammation existed. The 
surgeon first employed the antiphlogistic regimei., 
and then inserted a seton in the nape of the necK, 
which was regularly dressed in the morning. In 
eight or ten days they both declared that they had 
regained their hearing, and requested to be allowed 
to return to their duty. ( Cheyne.) As in the 



13C 



FEIGNED DISEASES. 



case of blindness, the natural but involuntary lan- 
guage of the countenance generally evinces that 
the impostor continues to gain intelligence of what 
is goin}{ on around him through the organ of 
hearing. Cases of this kind arc commonly de- 
tected by a little stratagem, such as making a sud- 
den noise near the patient, or suddenly mention- 
ing something deeply interesting to him, and 
watching the effect on his countenance or pulse. 
Fodere mentions several examples of soldiers who 
betrayed themselves on hearing a sudden noise. 
Mr. Dunlop mentions the case of a soldier in the 
York Military Hospital, who feigned deafness so 
well that firing a pistol at his ear produced no ef- 
fect. He was, however, detected by the same ex- 
periment made after he had been put to sleep by 
opium : he then started out of bed. (Beck's Ju- 
risprudence, p. 17.) 

Accident also has sometimes led to a discovery 
of imposture, when there was no suspicion enter- 
tained respecting the alleged loss of hearing. A 
remarkable instance of this is recorded by Sir 
Walter Scott, in the introduction to Peveril of the 
Peak. A woman pretending to be both deaf and 
dumb, lived several years in a family, and afforded 
no suspicion of being an impostor, until, on an 
occasion of great surprise, she forgot her part, and 
suddenly expressed her feelings " in loud Scotch." 
In the same work a beautiful illustration of the 
manner of detecting the imposture, by exciting 
strong emotion and watching its influence on the 
circulation, must be familiar to every reader. 

10. Deaf-dumbness. — This is a very com- 
mon imposture among mendicants. It is also not 
unfrequently feigned in the military and naval 
service. It is of importance to know, that if a 
person has ever acquired the use of speech and is 
able to move his tongue, his dumbness cannot be 
real. Many singular examples of this imposture 
are recorded by authors ; but the most remarkable 
is that of Victor Foy or Travanait, detailed at 
great length by Fodere. (Loc. cit. p. 478.) This 
man, after deceiving a vast number of medical 
men in different countries, was at length detected 
by the Abbe Sicard. Dr. Cheyne mentions the 
case of a soldier who exhibited this disability for 
no less a period than five years, but recovered his 
speech upon being discharged from the service. 
On one occasion this man was accidentally shot 
in the ear by an awkward recruit, on which occa- 
sion he " expressed pain and consternation by a 
variety of motions and contortions, but never 
spoke." (Loc. cit. p. Ml.) 

In a case of a seaman on board the Utile, who 
pretending to be deaf and dumb, the surgeon, ap- 
pearing to be deceived by him, made very formal 
and ostentatious preparations for an operation 
upon his throat, and while his attention was 
thereby engaged, he applied a lighted candle to 
the man's fingers. He resisted this test, however; 
and having represented his case to the Admiralty, 
the surgeon was dismissed his ship for cruel, or at 
least unprofessional, treatment of his patient. 
Shortly afterwards, the sailor being still detained 
in the ship, recovered both speech and hearing. 
He subsequently pretended to have lost his speech 
only ; but, finding that this faculty was not con- 
sidered essential to the performance of the severest 
duties of a seaman, he speedily regained his 



tongue. This man was of a very different temper 
from the simpleton of whom Parr speaks. " Hnw 
long have you been dumb, my good friend >" 
says a passenger, with the most insidious hu- 
manity. " Three weeks. Sir ;" replied the incau- 
tious deceiver. (Parr's Medical Dictionary.) 

1 1. Diarrhoea and Dysentery. — Bowel com- 
plaints are sometimes feigned by soldiers and sail- 
ors, and others, more particularly in countries 
where dysentery is prevalent, as in India. The 
motive for simulating this disease is commonly 
the escape from some particular duty. The im- 
posture is easily detected by obliging the patient 
to use a night-chair ; but care must be taken that 
he does not borrow, buy, or steal the leading 
symbol of dysentery, or manufacture it expressly 
for the occasion. Mr. Hutchinson informs us 
that he has known convicts break down in their 
urinary utensils a figured motion, and intimately 
mix it with the urine so as to induce the belief 
that it was in reality a diarrhccal evacuation, 
(Loc. cit.); and one of the writers of this article 
was informed by a West-Indian planter that the 
same deception is practised by the slaves in that 
country to escape labour. He knew an instance 
of a negro who had nearly rooted out all his teeth 
by tearing his gums with iron nails, in order to 
procure blood to make the factitious dysenteric 
motion more complete. These unhappy persons 
do not alwaj's content themselves with feigning 
these affections ; they actually produce them by 
deleterious substances taken into the bowels; and 
Mr. Hutchinson says he has not unfrequently 
known them fall victims to their own imprudent 
attempts. It would appear that the seamen under 
Mr. Hutchinson's care made use of vinegar and 
burnt cork to efiect their purposes. Mucous dis- 
charges are produced by introducing suppositories 
of soap or other irritating substances into the rec- 
tum, and these may be subsequently mixed with 
blood. {Cheyne, p. 170.) 

12. Ear, Diseases of. — A purulent and fetid 
discharge from the ear has been simulated or in- 
duced by soldiers with the usual object of obtain- 
ing their discharge or escaping from duty. An 
instance is mentioned in the Didionnaire des 
Sciences Medicales, where honey was used to 
simulate a morbid discharge ; and the cheat was 
very near proving successful. A more common 
practice is to introduce irritating substances, such 
as cantharides, into the auditory canal, and thus 
to excite inflammation and purulent discharge ; 
and to render the discharge more disagreeable, 
rancid oil, and other stinking matters have been 
afterwards employed. In these, as in so many 
other cases, careful examination will detect the 
imposition. 

13. Kmaciatiou and Debility. — An appear- 
ance of unsound health is occasionally simulated 
for the purpose of procuring an exemption from 
some disagreeable service, or to obtain leave of 
absence, change of climate, &c. The means 
commonly employed are abstinence from sleep 
and food for a considerable time, drinking to 
excess of strong liquors, and frequently taking 
small doses of the tartrate of antimony. 

Partial emaciation, or wasting of "the limbs, re 
a much more common resource of the impostor, 
more particularly among mendicants. In the 



FEIGNED DISEASES, 



131 



army or navy it is hanlly possible for the indi- 
vidual to find time or opportunities to produce 
the compression by which it is effected. Some- 
time3, however, the circumstance, not very rare 
among adults, of one arm being considerably 
smaller than the other, is taken advantage of, and 
the impostor pretends that the wasting is of recent 
occurrence, and is accompanied with loss of mus- 
cular power or with pain. The Earl of Glouces- 
ter, afterwards Richard III., had an arm of this 
sort, and is related to have taken advantage of it 
for purposes of deception. 

Every one must have seen mendicants at coun- 
try fairs, exhibiting one or both arms hanging 
down fleshlcss and motionless by their sides. 
Almost all these have been in the first place in- 
tentionally produced by long-continued bandaging, 
and the greater number have in reality become 
powerless. 

Partial wasting of a limb may, however, be a 
real disease ; we are not, therefore, to decide on 
such cases without due examination. In most 
instances the knowledge of the surgeon will ena- 
ble him to discriminate between the real and the 
pretended disability ; but we have known in- 
stances in which the discrimination was extremely 
difRcuit. 

14. Epilepsy. — This disease is very frequent- 
ly simulated in the streets. It is also not seldom 
feigned by soldiers and sailors for the purpose of 
procuring their discharge. Nevertheless, the prac- 
titiouer who is intimately acquainted with the pa- 
thognomonic symptoms of epilepsy, and pays pro- 
per attention to the case, will generally be able to 
satisfy himself whether an alleged paroxysm of 
the disease be simulated or not. During a feigned 
paroxysm of epilepsy the contractions of the dif- 
ferent parts of the body do not come on simulta- 
neously ; and if a patient be narrowly watched, 
he will be discovered to open his eyes occasionally 
for the purpose of observing what effect his exhi- 
tion has upon the by-standers. The simulator of 
epilepsy is unable to produce the red, bloated 
countenance and contorted face which accompany 
the real disease, or the immobility of the iris on 
the access of light. He is also apt to exhibit the 
appearance of foaming at the mouth either in too 
slight or in too great a degree. The latter result 
is produced by a piece of soap kept in the mouth. 
A marked difference between the real and feigned 
disease is, usually, that in the latter the patient 
courts publicity for his exhibitions, and makes no 
attempt to conceal his malady, while the real epi- 
leptic is almost always extremely desirous of hid- 
ing his infirmity. It will, likewise, be found on 
'nquiry, that the feigned paroxysm is apt to come 
on very opportunely to promote the attainment 
of some object of desire to the patient, while the 
real disease shows no such intelligent considera- 
tion. It is further to be observed, that the skin 
is comparatively cool when the contraction of the 
muscles is involuntary ; but if the agitation of 
the body be voluntary, the skin is covered with 
perspiration. A feigned paroxysm of epilepsy 
usually terminates much more abruptly than the 
true disease, and the convulsions are not succeed- 
ed by the comatose or soporose state that gene- 
rally supervenes on the epile[)tic convulsion. 
The most decided proof of epilepsy is, however, 



an insensibility to the influence of external agents ; 
consequently, when any evidence of sense is ex- 
cited by stimulants during the paroxysm, it may 
generally be inferred that the symptoms are coun- 
terfeited. For the purpose of testing the degree 
of insensibility, various means may be tried in 
doubtful cases. The following are some that have 
been used by military and naval surgeons, and 
often successfully. 

1. A powerful general shock to the system, as 
by a pailful of cold water suddenly dashed upon 
the patient. We have more than once seen this 
treatment succeed in putting a period to the par- 
oxysm ; but we did not always, on this account, 
satisfy ourselves that the disease was feigned. So 
powerful a shock is not unlikely to arrest real 
convulsions. 

2. A strong impression made upon particular 
senses. Mr. Hutchinson mentions a case supposed 
to be feigned in which the convulsions were in- 
stantly removed b}- blowing " some fine Scotch 
snufl"" up the nostrils through a quill. This in- 
duced another fit — a fit of sneezing — that lasted 
nearly a quarter of an hour ; and there was no 
return of the epilepsy while Mr. Hutchinson re- 
mained in the ship. The same practice was tried 
in real cases of epilepsy by this gentleman, but 
he never could produce any similar effects, al- 
though the patients were not snufi-takeis. Dr. 
Cheyne thhiks the most powerful stimulant that 
can be used in such cases is a few drops of alco- 
hol introduced into the eye, and relates a case 
where the pretended epilepsy was instantly arrest- 
ed by it. The introduction of stimulating or very 
nauseous remedies into the mouth, so as strongly 
to impress the sense of taste, — stutfing the mouth 
with common salt, or forcibly introducing a solu- 
tion of aloes, &c., is thus often effectual in putting 
an end to the feigned disease. 

3. The apprehension of pain or danger, excited 
by the proposal of an operation in the patient's 
hearing, or by actually placing him in a situation 
where he must injure himself if the convulsive 
movements are continued. We are informed by 
a naval officer that he once saw a tremendous 
epilepsy instantly cured by an order being given 
to introduce a red-hot ramrod into the patient's 
anus ; and the dread of the actual cautery, though 
in a somewhat less formidable mode, has often 
proved a powerful remedy in similar cases. Per- 
haps an equally effectual plan is to propose to 
pour boiling water on the legs, and actually to 
pour cold water. Dr. Cheyne relates an ingeni- 
ous expedient put in practice in a case of feigned 
epilepsy, by Mr. Young, surgeon of the 10th re- 
giment. A large barrack-table was put upou :.n- 
other of the same dimensions, and the pretender 
placed, in the midst of his paroxysm, upon this 
elevated bed. The fear of a descent put an im- 
mediate termination to the epilepsy. (Loc. cit. p. 
1.54.) 

In concluding those remarks, we wish to im- 
press upon the mind of the young praclitione<- 
that he is not to be too positive in imagining tnat 
he will always be able to decide with certainly 
whether the ostensible epilepsy is feigned or real 
In all doubtful cases, it is due to his own charac- 
ter as a man of honour and feeling, and due lo 
the beneficent profession of which he is a mpm- 



132 __ 

ber, that he take the side of mercy ; and if he is 
ever justified in denouncing a patient as an im- 
postor, and thereby consigning him to punishment, 
he is certainlv never justified in being himself the 
instrument of the punishment. Dr. Cheyne, a 
man of the greatest experience, and distinguished 
aUke for his candour and accurate observation, 
informs us that he is " in possession of sufficient 
evidence to prove that real epilepsy has often 
been considered feigned ;" and our own experi- 
ence irresistibly leads us to adopt the same con- 
clusion. 

15. Kxcretion of CalcuU, &c. — Soldiers 
sometimes feign this afl:ection with the view of ob- 
taining their discharge, and unwilling recruits to 
prevent their serving in the army. A fit of ne- 
phralgia, or passing of gravel, is even pretended, 
and an alleged calculus exhibited. A similar im- 
position is practised by females, and occasionally 
under such circumstances as render it very diffi- 
cult to account for their conduct. A most re- 
markable case is recorded in the Edinburgh Me- 
dical Journal (vol. vii.) of " a young lady, of 
rather high rank," who feigned this disease, and 
was believed to have excreted, with great pain, a 
vast quantity of calculi, " not less than several 
pint measures in two or three years." The rudest 
chemical experiments proved the pretended calculi 
not to be of animal origin ; they were in fact, 
" common sand and pebble stones." No motive 
cbuld be assigned for this extraordinary conduct. 
A similar case in a boy, ten years of age, is men- 
tioned in the Annals of Philosophy, vol. iv. p. 76 ; 
and Dr. Thomson of Edinburgh discovered a simi- 
lar imposition in a woman, by detecting micaceous 
particles in the alleged gravel. (Beck's Jurispru- 
dence, by Dunlop, p. 7.) 

A still more common deception perhaps, and 
one much more extravagant, is the pretended ex- 
cretion of calculi from the vagina. Many instan- 
ces of this fact are mentioned by authors, and 
many others might be added. In a case mentioned 
in the Medical Comm., vol. iv. calcined bricks 
were pretended to be passed from the vagina, and 
some were extracted from it. A case was men- 
tioned to us not long since, of a young woman 
from whom many fragments of coal were extracted 
by a surgeon. But the most remarkable instance 
of imposition that has come to our knowledge is 
that of a young woman, the daughter of a farmer 
near Edinburgh, who, after feigning, forming, or 
sustaining an immense variety of affections, in 
uninterrupted series, from 1817 to 1830, at length 
fixed upon the excretion of bone from the vagina 
as the great and abiding malady. Among the 
diseases, real, feigned, or factitious, which this girl 
exhibited, were hepatitis, epilepsy, amaurosis, 
aphonia, deafness, paralysis of the arm, gravel, 
anasarca, haematemesis, irregular convulsions, gas- 
traigia, dyspnoea, vomiting of substances resem- 
bling liver and bone, and retention of urine. 
Bone was first detected in the vagina in 1824, 
while the surgeon was introducing the catheter, 
and from this period an immense quantity was 
either extracted or excreted ; some pieces were 
even extracted from the bladder. She was admit- 
ted into an hospital in 1825, where she still con- 
tinued to pass bones, believed for some time to be 
tpoao of an extra-uterine foetus; but a complete 



FEIGNED DISEASES. 

stop was put to the complaint by secluding the 
patient from all access to such materials. After 
her discharge the alleged excretion returned. She 
had an illegitimate child in 1828, and was finally 
married to a respectable farmer in 1830. Another 
young woman, in a respectable rank in life, pre- 
tended to pass vesicular bodies from the vagina, 
and many were extracted by surgical aid. At 
first the disease was considered natural, but eventu- 
ally it was discovered by Professor Thomson of 
Edinburgh, that the alleged hydatids were artifi- 
cial vesicles prepared from the intestines of a pig. 
These were so constructed as to resemble a string 
of beads. 

It is hardly necessary to say anything respecting 
the means of detecting such impositions ; it is, 
however, important that the young practitioner 
should be made aware of their occasional existence. 

16. Fever. — This disease is frequently feigned, 
and also in some degree produced artificially. 
Soldiers and sailors pretend to have an accession 
of ague during the night, and present themselves 
as if in the interval to the surgeon. Sometimes 
they simulate the fit at a time when they can 
be more readily discovered. Dr. Cheyne men- 
tions the case of a soldier who pretended to be in 
a chill, and who was seen to be shaking violently: 
upon throwing down the bedclothes, however, he 
was found not in the cold, but it in a sweating 
stage produced by his own exertion. This expo- 
sure put an immediate termination to the parox- 
ysm. (Op. cit. p. 175.) Such persons, Foilere 
says, often imitate admirably the chattering of the 
teeth of the cold fit. They likewise use means to 
produce a greater semblance of fever. Great heat 
and perspiration, and a quick pulse, are produced 
by strong exercise immediately before the hour of 
the visit. In the section on disordered circula- 
tion, we have noticed various means adopted for 
the purpose of disordering the action of the heart 
and arteries, most of which are equally applicable 
to the production of the disease now under con- 
sideration. The skin is sometimes scrubbed with 
a hard brush to produce redness ; and the tongue 
is very frequently coloured artificially white, 
brown, or dark, with chalk, pipe-clay, tobacco, 
brick-dust, and brown soap, &c. according to the 
convenience or knowledge of the impostor. The 
sanguinary pirate Loto, who was lately executed 
at Gibraltar, very nearly succeeded in deceiving 
his medical attendants by simulating fever, colour- 
ing his tongue brown, &c. In all these cases close 
observation will almost always detect the impos- 
ture ; and most certainly a few days' confinement 
will do so. It is only an ephemeral fever that can 
be feigned with any prospect of success. 

17*. Fracture. — We have seen several soldiers 
who simulated lameness, and alleged that a thigh 
bone had been fractured, by which means the 
limb had become shortened.' This imposture is 
easily detected by placing the man upon his back 
and examining both the thighs : the muscles of 
the limb falsely alleged to be shortened will be 
found hard and in full action, while the muscles 
of the other limb are inactive and soft. We hap- 
pened to know one instance of a soldier who ob- 
tained his discharge by alleging that he had a 
plate of metal in hU skull, which he said had been 
introduced there in consequence of the bone hav- 



FEIGNED DISEASES. 



133 



ing been fractured ; and we are also aware of an 
instance where a medical officer was found fault 
with for having approved of recruits " with plates 
introduced into their heads." The simulators of 
this disability must have met with very credulous 
auditors, for it is to be presumed they did not ex- 
amine the heads said to be thus mended. 

18. Hjeinatemesis« — This affection is readily 
simulated, and frequently has been so by soldiers, 
sailors, slaves, and other persons. It is effected 
by procuring blood, and after swallowing it, pro- 
ducing artificial vomiting, whereby it is disgorged. 
The blood is generally that of some animal ; but 
slaves in the West Indies have been known to 
swallow their own blood to effect their object, A 
reznarkable case is mentioned by Sauvages, of a 
girl who feigned hsmatemesis to escape from a 
convent, and who brought up in the presence of 
the physician several pounds of blood on several 
successive days. It was at last discovered that 
she secretly drank bullock's blood before the visit. 
(Nosol. Method, ii. p. 299.) This imposition will 
in general be discovered at least in situations 
where the medical attendant may reasonably ex- 
pect to meet with feigned diseases, by narrowly 
examining the symptoms — when a discrepancy 
and want of harmony will be found among them 
which nature never presents. When any suspi- 
cion is excited, the detection may be ma<le at 
once by watching the patient, and cutting off the 
possibility of his obtaining the materials necessary 
to the simulation. 

19. Hsematiiria. — This disease has been 
sometimes simulated by taking substances into 
the stomach which have the quality of reddening 
the urine, such as beet-root, the fruit of the prick- 
ly pear, madder, &c. ; it has, however, been much 
more frequently attempted to impose by mixing 
foreign substances with the urine, particularly 
blood, after it was excreted. The authors of the 
article Feigned Diseases in the Dictionnaire des 
Sciences Medicales inform us that blood has even 
been injected into the bladder with this view. A 
little attention suflices to discover factitious haema- 
turia, however produced. 

20. Htvmoptysis. — This is a disease very 
commonly feigned by soldiers and sailors, and 
also by mendicants. The cough is easily assum- 
ed, and the sanguineous expectoration is produced 
by pricking or cutting the gums, throat, or some 
part of the mouth, or by cutting the fingers or 
arm and sucking the blood, or by procuring the 
blood of animals, or by artificially tinging the 
sputa of a red colour by some foreign substance. 
Sylvaticus mentions the Armenian bole as being 
used for this purpose, (Institutio medica de iis 
qui morbum simulant dcprehendendis. — Madrit. 
1594) ; Dr. Beck, brickdust ; and Mr. Hutchison, 
vermilion paint. Dr. Cheyne justly observes, that 
the absence of the symptoms which generally 
attend real haemoptysis, such as cough, dyspnoea, 
fever, &c. will naturally excite suspicion, and the 
appearance of the sputa will confirm this in such 
cases. The factitious will be very unlike the real 
sputa of haemoptysis. The use of the stethoscope 
will greatly aid in the diagnosis in doubtful cases. 
ft ought to be a rule in the army, that simple 
spitting of blood, unaccompanied by signs of 



organic disease of the lungs, is not a sufficient 
cause for the discharge of a soldier. 

21. HcemorrUoids. — The discharge of blood 
from the anus is easily feigned or imitated. It 
appears also that haemorrhoidal tumours have been 
very artfully constructed by means of small blad- 
ders, inflated and tinged with blood, and attached 
to a substance introduced into the rectum. {Percy 
and Laurent, op. cit.) 

22. Mei>atitis. — This affection is often simu- 
lated by soldiers who have been some time in 
India, when they wish to be discharged. They 
are commonly well acquainted with the symptoms 
of the disease, and frequently tell a tolerably con- 
sistent story. The countenance and general ap- 
pearance of an impostor of this kind, are, however, 
often at great variance with his oral testimony. 
In doubtful cases of alleged organic disease of the 
chest or abdomen, the person to be examined 
should be undressed, as he is then unable to con- 
ceal whatever evidence of health may be supplied 
by a plump frame and muscular limbs. An op- 
portunity is also thus afforded of properly explor- 
ing the cavity in which the disease is alleged to 
have its site. 

It is not an uncommon practice with officers in 
the navy on foreign stations, who are desirous of 
returning to England, to feign some disease in 
order to be invalided to a more temperate climate. 
In the West Indies in particular, this practice 
was formerly of frequent occurrence ; and it is a 
curious fact that the disease most frequently as- 
sumed, and successfully, was that now under 
consideration, and which is by no means very 
common among sailors in that country. The 
causes of this preference in favour of hepatitis are, 
111) doubt, the supposed facility of imposing the 
belief of its existence on a superficial observer, 
anil the generally received opinion of the tendency 
of all tropical climates to generate it. 

The facts just stated might lead to some curious 
statistical mistakes. Suppose, for instance, infor- 
mation were sought respecting the relative preva- 
lence of different diseases in different climates 
among persons in the navy. If the official records 
of the medical department were inspected for this 
purpose, it would be found that a large portion of 
the invalids from the West Indies were aflected 
with hepatitis; and it is probable that the propor- 
tion might be greater than among the invalids 
from the East Indies. Now there cannot be a 
doubt that liver-disease is, in truth, much more 
prevalent in the latter climate than in the former. 
Owing to particular circumstances those invalided 
for complaints of this kind from the West Indies 
are chiefly officers ; and the much greater propor- 
tion of this class than of common seamen, in the 
invalid lists, might be considered as indicating 
some peculiar causes of hepatitis among officers 
in that country. 

Dr. Cheyne has some very sensible remarks on 
the feigned hepatitis of soldiers. He says that 
" when men who have not Leen in warm climates 
obstinately coir» iain of pain in the right hypo- 
chondrium, and when we cannot discover any en- 
largement or fulness of the liver, when the puist? 
and breathing are undisturbed, the secretions and 
excretions natural, and when the alleged pain rp 



134 



FEIGNED DISEASES. 



sists topical bleeding and blistering, and mercurial 
purgatives, the sooner we send them to duty the 
better." Persons in this class often eventually 
succeed in their object of dismissal from the ser- 
vice, chiefly from the mistakes of the surgeon. 
"Such subjects," says Dr. Chej-ne, " have often 
come under my care with their flesh and strength 
reduced by repeated courses of mercury, their 
gums absorbed, and teeth shaking in their sockets, 
whose livers were sound (probably they never 
were otherwise), but whose broken health required 
that they should be invalided without delay." 
(Loc. cit. p. 172.) 

23. Hernia and Hydrocele. — Both these 
diseases have been frequently simulated. The 
means most frequently used to eflfect the object, is 
inflating the cellular substance of the scrotum. 
But more artful and more severe means have been 
adopted. Cases are related in the Act. Nat. Cur. 
of inflated bladders being applied to the scrotum 
to impose on the ignorant ; and it is to the great 
discredit of the medical profession that some of its 
members have aided in the production of decep- 
tions of a more scientific description. In the year 
1828, two medical men were tried in France for 
having respectively, produced in four conscripts 
swellings of the te^ticles. It was sworn by one 
of the conscripts that the operator injected into a 
wound made by him in the scrotum, a red-coloured 
liquid which gave him excessive pain. The ope- 
ration was followed by violent inflammation of the 
testis. The other operator applied caustic to the 
scrotum with the same result. This last indivi- 
dual, a surgeon of the name of Desplats, was sen- 
tenced to the pillory and five years' imprisonment. 
The practice of inflating the scrotum is much 
more common, because more easy. Sir Astley 
Cooper mentions the case of a man at Norwich 
who imposed on the surgeon by this means, and 
thus escaped serving in the army ; and we have 
more than once seen the same plan adopted, but 
without success, by impressed seamen. A small 
blow-pipe, or the stalk of a tobacco-pipe, is the 
instrument commonly used. It is hardly neces- 
sary to say that no surgeon ought to be deceived 
by a case of this kind. 

Some men have the power of retaining the 
testes in the groin by the voluntary action of the 
cremasler muscles; and the swellings resulting 
from such a position of the parts have been mis- 
taken for hernia. (Hutchinson, loc. cit.) 

24. Hydrocephalus. — Chronic hydrocepha- 
lus has been simulated, at least in one case which 
we shall quote from Sauvages, who terms the case, 
after Mangetus, physocepkalus artificial} s. In 
the year 1593, a mendicant exhibited his child for 
gain as a monster, on account of the immense 
size of his head. This preternatural appearance 
was produced by the daily insufflation of air under 
the scalp, by means of a pipe introduced into a 
small perforation on the vertex. By this opera- 
tion, repeated for several months, the scalp at 
length became extended to an enormous degree. 
Being detected, this wicked father was condemned 
to death. (Nosol. Method, t. ii. p. 497.) 

2.5. Hydropliobia. — One would hardly ex- 
pect that this disease should ever have been feigned. 
MM. Percy and Laurejit, however, mention a case 
jf the kind in a conscript, which, although terri- 



fying the examiners at first, was eventually cured 
by the threat of suffocation between two beds. 

26. Incontinence of Faeces. We have 

known this disease feigned. A boy on board the 
Desiree frigate pretended that he could not retain 
his faces, and was frequently found voiding tliem 
on all occasions and in all places. Being deemed 
an impostor, he was severely punished, and at last 
confessed that he had been advised to do so by his 
aunt, that he might be discharged the service : this 
result he was very near obtaining. The following 
remark of Dr. Cheyiie, relative to this pretended 
malady, is very judicious. " When a patient al- 
leges that he cannot retain the contents of the 
bowels, the sphincter ani ought to be examined, 
and if it contracts upon the finger, opium, with 
solid food must be prescribed, and a watch set over 
the individual : if he passes solid fseces in bed, he 
will be a fit subject for a court martial. " 

27. Incontinence of Urine. — It is somewhat 
singular that a disease so very rare as this is among 
persons not advanced in life, should be one very 
commonly feigned, more particularly by soldtere. 
This arises, probably, from the circumstance that 
the infirmity is easily simulated, and is one particu- 
larly inconsistent with the habits of neatness and 
cleanliness required in a modern soldier. This 
disease was extremely common among the French 
conscripts during Napoleon's wars. Its very fre- 
quency of occurrence among soldiers is in itself a 
strong presumption of imposition ; and if it makes 
its appearance at all in an epidemic form, we may 
be almost certain that it is feigned. MM. Percy and 
Laurent say they have had no fewer than fifteen 
pretended cases of this kind at one time in a recruit- 
ing depot ; and Fodere witnessed its occurrence, 
almost in an epidemic form, in consequence of two 
soldiers having obtained their discharge on this ac- 
count. Dr. Cheyne notices a somewhat similar 
circumstance in an English regiment, in conse- 
quence of the facility the soldiers found in impos- 
ing upon a practitioner unacquainted with mili- 
tary practice. 

Independently of evidence derived from collate- 
ral circumstances, there are many means of de- 
tecting simulated incontinence. When the dis- 
ease is real, the clothes of the individual usually 
exhale a strong ammoniacal odour, which is not 
often the case when the disorder is feigned. The 
simulator commonly chooses the time and place 
which appear to him the best for wetting his 
clothes: if he sleeps with another person, he is 
more apt to wet his bed than when he sleeps 
alone ; and if he is furnished with clean straw to 
lie upon, he does not commonly wet it before the 
morning. In real incontinence, more especially 
if it has existed some time, the glans penis is 
stated by MM. Percy and Laurent to be pale and 
shrivelled, from being kept constantly wet with 
the urine which comes away gut tat irn; and Fo- 
dere says, if a ligature be passed round the penis 
in such cases, the urethra will soon be found dis- 
tended above it. It is evident, however, that this 
test cannot be depended upon. In the Austrian 
army, a man who alleges that he has incontinence 
of urine is furnished with a urinal, and obliged to 
do his duly. In the French army it was custom- 
ary to compress the penis between two pieces of 
wood ; and Fodere informs us that he succe ' 



FEIGNED DISEASES. 



135 



in putting a stop to a fictitious epidemic of this 
kind by applying a sealed ligature to the penis, 
which was only allowed to be undone by a person 
appointed for the purpose. MM. Percy and Lau- 
rent prescribed with perfect success in a case of 
this kind, twenty lashes on the loins, with the 
avowed object of strengthening the debilitated 
part ; and the surgeon of a regiment mentioned 
by Dr. Cheyne, speedily put an end to a pretended 
epidemic of the same kind by prescribing a cold 
bath twice a day in Lough Neagh. Such means 
as these, with blisters to the perineum, and other 
a[)propriate but disagreeable remedies, will almost 
always put an end to this alleged disability, even 
when we have not been able to demonstrate to the 
simulator himself that we have detected him. 
When this is once effected, there is never any dif- 
ficulty in curing any feigned disease. The most 
effectual mode of detecting simulated incontinence 
is that prescribed by Mr. Comyns, an army sur- 
geon, and afterwards by Dr. Hennen and Mr. 
Hutchinson, viz. to administer a strong opiate at 
bed-lime, and to watch the length of time the 
urine is retained during sleep; or to introduce the 
catheter unexpectedly, to ascertain the quantity 
of urine found in the bladder. In real inconti- 
nence, the bladder will not retain its contents after 
a certain time during sleep, or under any other 
circumstances. The following ingenious method 
was successfully used by an army surgeon to de- 
tect and cure a fictitious infirmity of this kind. 
The surgeon having ascertained from the patient 
how long he could retain his urine, (of course a 
very short period,) caused him to undress and 
stand before him with the abdomen exposed. 
Upon observing the abdominal muscles called into 
action to aid in the expulsion of the urine, he 
suddenly and forcibly thrust his fingers against 
the belly so as to prevent the voluntary muscular 
effort. This he repeated as often as he saw the 
action renewed, until the alleged period of expul- 
sion was long passed. He then dismissed the pa- 
tient with the remark that he had retained his 
urine long enough to enable him to do his duty. 

The opposite state of 7-etention of urine has 
been sometimes feigned, more particularly by fe- 
male convicts. A strict watch will always detect 
such an imposition. 

28. Jaundice.— The yellow colour of the skin 
in this disease has been simulated by painting it 
with an infusion of curcuma or tincture of rhu- 
barb, &c. ; and it is said clay-coloured stools have 
been imitated to perfection by taking daily a small 
quantity of muriatic acid. What it is impossible 
to feign or to form, however, is the yellow colour 
of the conjunctiva, and the want of this will al- 
ways detect the imposition. It will rarely happen 
that a simulator will be so ingenious as to produce, 
at the sam'e time, the yellow skin, the pale stools, 
and the dark-coloured urine. An ingenious de- 
vice for altering, at least, if not rendering yellow, 
the conjunctiva, was that of a French conscript, 
who always put snuff in his eyes before the sur- 
geon's visit. (Diet des Sci. Med. loc. cit.) 

29. Madness. — Mental derangement, in some 
of its forms of idiocy, melancholia, or mania, has 
been in all ages assumed as a means of attaining 
certain objects of desire. The names of many 
per!»ons famous in ancient and modern time's are 



associated with this imposture. Madness is most 
commonly feigned in civil life by prisoners to 
escape punishment. In the army and navy, and 
among slaves, it is feigned with the same object, 
as well as to escape from disagreeable labour; but 
in the army and navy it is still more commonly 
feigned with the view of obtaining a discharge 
from the service. In the latter department of the 
public service, during the late war, in which so 
many hearts were broken by the hope too long 
deferred of returning home, every surgeon of ex- 
perience met with instances of simulated insanity; 
and it was equally common among the numerous 
prisoners of war detained for so many years in this 
country. All the forms of disordered intellect 
were feigned ; but the most common was that of 
furious madness, assumed with the view of effect- 
ing a temporary purpose, such as the evasion of 
punishment, the removal to an hospital, &c. 
When the design was to obtain a discharge fi-om 
the service, melancholia or idiocy was the form 
adopted. In several instances the simulators suc- 
ceeded in gaining their ends ; in many others 
they were detected ; and we fear that in not a few 
instances real insanity was mistaken for feigned, 
and the patients were treated as impostors. This 
fact ought to lead the medical officers in the pub- 
lic service to study with great care the indications 
of insanity, and ought moreover to induce them, 
whenever there is a shadow of doubt, to lean to 
the side of mercy. It is infinitely better that they 
should be deceived, than that a poor wretch, al- 
ready suffering under the most grievous of natural 
calamities, should undergo additional misery from 
their ignorance. 

The discrimination of the fictitious from the 
real disease is not always so easy as those who 
have never witnessed both are apt to imagine. It 
is true that when we consider the very peculiar 
and complex phenomena which characterize true 
madness, and reflect on the general ignorance of 
those who attempt to imitate them, we have no 
right to expect such a finished picture as could 
impose on persons well acquainted with the real 
disease. And yet when, on the other hand, we 
consider how imperfectly the operations of the in- 
tellect, both in a state of health and disease, are 
known to medical men in general, and how few 
opportunities the medical oflnicers in the public 
service have of observing the phenomena of in- 
sanity, and reflect how natural it is for the feelings 
of honourable men to take the part of ostensible 
distress, it need not surprise us that the pictures 
drawn even by such rude hands have imposed on 
educated minds. But it is less because fictitious 
madness has been treated as real, than because 
real madness has been treated as fictitious, ihul 
we are so anxious to direct the attention of iuiiior 
medical officers in the army and navy to the studv 
of the characteristic features of the disease. Thesis 
can be only thoroughly studied in the receptacle!- 
for the insane, but much knowledge "■f import 
ance may be derived from books. Referring llit 
reader to these sources, we nmst content our 
selves in this place with a few general observ.-i 
tions. 

The form of madness that can be assumed with 
most facility is that of furious mania ; and yet the 
cases of this which we have witnessed have been 



136 



FEIGNED DISEASES. 



all lamentably defective as imitations of nature. 
The actors always overdid tlieir part. They sought 
to personify the'notion of madness usually enter- 
lained bv the vulgar, viz. the total abolition of the 
rational faculty, instead ot its partial perversion. 
It is still more' difficult to simulate the quiet half- 
rational insanity of the melancholic or monoma- 
niac ; as nothing but careful observation of persons 
so affected can qualify an individual for such a 
difficult task. This statement might be illustrated 
in a curious and interesting manner by a reference 
to the writings of poets and novelists. Such per- 
sons are obviously much better qualified to paint 
the disease now under consideration, than the 
ignorant soldier or sailor; and yet it would not be 
difKcult to point out, in the numerous delineations 
of insanity presented by authors, such glaring de- 
viations from nature as could not fail to strike 
any one versed in the history of the disease. 
Shakspeare, Goiithe, and a few others perhaps, 
might stand the application of the severest test ; 
but the common class of writers who have attempt- 
ed such delineations have failed completely. 

Idiocy has been more successfully imitated ; 
and, perhaps, this may be accounted for by the 
opportunities which most men have enjoyed of 
studying the character in the instance of the poor 
idiot, still to be met with at large in almost every 
village. Conscri{)ts have pretended that they were 
incapable of being taught the commonest duties 
of a soldier ; and we knew an instance of a young 
player, drafted into the army, who acted the part 
of an idiot so effectually that he soon obtained his 
discharge. Almost immediately after this he en- 
listed into another regiment, and then deserted. 

Independently of the mental phenomena of in- 
sanity, there are many physical conditions of the 
system often present in this disease, which it is 
hardly possible to feign, such as the expression of 
the countenance, the state of the eye, of the tongue, 
&c. One very common symptom, and one indeed 
invariably present in the earlier stages of furious 
mania, and in most of the forms of monomania, 
is sleeplessness; and this it is hardly possible for 
any man to feign. A real madman will be many 
days, even weeks, without sleep. This circum- 
stance, alone, if properly taken advantage of, will 
suffice to detect most impostors ; and in order to 
derive from it all the advantages which it is capa- 
ble of yielding, a strict and uninterrupted watch 
should be kept on all patients who are suspected 
of imposition. In the case of a seaman who en- 
acted under our own eye the part of a furious 
maniac, in hopes of escaping punishment, sound 
sleep overpowered him on the second night of his 
attempt. Abstinence from food is another circum- 
stance respecting which there will often be ob- 
served a marked discrepancy between the real and 
the pretended madman. 

A strict watch will also generally detect in the 
simulated disease, great variations of violence, 
incoherence, or other symptoms, having reference 
to the visits of the medical officer, the being over- 
looked, &c. A pretended maniac will often be 
tranquil when he believes himself alone, or only 
in the presence of those of whose opinion he is 
regardless. A bold and clever dissembler will, 
however, not leave himself thus exposed to detec- 
tion. We are informed by a gentleman, once in 



charge of French prisoners of war in this country, 
that he has known men (afterwards detected and 
admitted on their own confession to be impostors) 
carry their simulation to so exquisite a height as 
to eat their own excrements, even when shut up 
in their cells, suspecting they might be over- 
looked. 

Real madness is seldom sudden in its attack ; 
feigned madness very generally is so. The real 
disease usually exhibits itself at first in slight and 
almost imperceptible deviations from the habitual 
modes of thinking and acting, not reaching its 
height in many cases until after a progressive in- 
crease of months, or even years ; although, per- 
haps, the change at last from a comparatively 
slight degree of hallucination to extreme violence 
has been sudden. The feigned disease, on the. 
contrary, is rarely preceded by such indications, 
but bursts out in full violence at once, upon the 
application of some exciting cause. And yet this 
rule is not without exception in both cases. We 
have seen instances of sudden and furious insanity 
in civil life, without any premonitory sign. 

The circumstances under which the alleged in- 
sanity has supervened, the man's previous charac- 
ter, the probability or improbability of the disease 
being assumed, and many other obvious consider- 
ations, will all materially assist the diagnosis. For 
instance, if we find a man not previously liable to 
be so affected, nor hereditarily disposed to insa- 
nity, suddenly exhibit the appearance of this dis- 
ease, under an impending trial or punishment, or 
other threatened evil, which might be averted by 
such a state, there is certainly a presumption in 
favour of the disability being feigned. It is, how- 
ever, to be borne in mind, that the very same ap- 
prehension of exposure, disgrace, or punishment, 
which affords motives for simulating insanity with 
the view of escaping them, may give rise to the 
real disease. Instances of this kind have been 
mentioned to us as occurring in the public ser- 
vice, and it would be easy to supply others from 
history and the records of jurisprudence. For this 
reason, and because we believe, with Dr. Cheyne, 
on other grounds, that " we are in more danger 
of supposing insanity simulated when it is real, 
than of considering that disease to be real when 
it is only pretended," we must strongly protest 
against the decision in any case, that the disease 
is feigned, solely because there appears a strong 
reason for its being so. Taken in conjunctioit 
with the actual phenomena and other collateral 
circumstances, the consideration of the probable 
motives will, however, no doubt, in many case* 
greatly aid the diagnosis. 

The existence or non-existence of causes known 
to predispose to insanity will be considered in 
every particular case, and they will havcj their due 
weight. Of this kind are previous attacks of the 
same malady, under circumstances where there 
existed no apparent motive for deceit ; the exist- 
ence in the patient's family of a similar disease; 
eccentric habits, or what may he termed the ma- 
niacal temperament; a decidedly strumous habit; 
the application of strong exciting causes of a mo- 
ral nature ; physical disorders, especially 'iuch as 
are known to affect the brain, as prolonged intoxi- 
cation, previous injury of the head, the repression 
01 cutaneous eruptions, &c. dfec. 



FEIGNED DISEASES. 



137 



It is well remarked by Dr. Cheync, that in real 
insanity there is often the greatest insensibility to 
decency, propriety, and comfort, evidenced by the 
grossest language in persons previously of very 
pure minds, by exposure of the person, spitting 
heedlessly in all directions, passing the excrements 
in bed, or plastering them on the walls of the cell, 
&c. circumstances not likely to exist, at least in 
the same degree, in simulated cases. Yet this 
only affords us collateral aid in the diagnosis. Fo- 
dere has related the case of a young woman, un- 
doubtedly a pretender, who committed every kind 
of indecency in her cell ; and the miserable trait 
formerly noticed, of a prisoner of war devouring 
his own excrements, is a convincing proof that 
nothing is too disgusting to appal a determined 
will. 

In addition to the means of diagnosis sup[)lied 
by the actual phenomena of the malady, by its 
previous history, and by other collateral circum- 
stances, we have, in suspicious cases, a very im- 
portant means in the institution of plans calcu- 
lated to outwit an impostor or to overcome his ob- 
stinacy. Many harsh measures have been had re- 
course to in the army and navj-, with this view, 
which are altogether unjustifiable, except in cases 
of the clearest imposture. In no case, hovvever 
suspicious, is the medical practitioner authorized 
to go beyond the employment of means of a 
strictly professional kind. He may, indeed, use 
all the artillery of annoyance supphed by medi- 
cine, and he may even threaten extra-professional 
infliction, but he must never go beyond this line. 
When convinced of the imposition in the case of 
a soldier or sailor, it is the duty of the medical 
officer to state his opinion to his military supe- 
riors ; the punishment of such a crime is altoge- 
ther foreign to his station and profession. Still, 
both the threat and the actual infliction of punish- 
ment have often put an end to simulated madness. 
In a case which occurred in the navy, a sailor 
who evinced a great desire to throw himself over- 
board, but was for a time prevented, at length 
succeeded in doing so ; immediately on reaching 
the water, however, he began to swim vigorously, 
and called loudly for a boat. Upon being taken 
on board, his madness had disappeared, and it did 
not return. 'I'he practice of former times would 
sanction a conjecture that this might be a case of 
real insanity cured. In the case of the girl men- 
tioned by Fodcre, his informing the keeper in her 
presence that on the morrow a hot iron would be 
applied between the shoulders if she was not bet- 
ter, was immediately followed by great amend- 
ment. Actual punishment has often been advised, 
and even employed, where there existed merely 
suspicion of imposture ; and, although condemn- 
ing the practice, we must admit that it has fre- 
quently been successful in detecting deceit. Zac- 
chias relates a case in which a physician recom- 
mended corporal punishment, on the principle 
that, if the madness were simulated, the cheat 
would not stand the test, and if it were real, the 
flagellation would do good as a derivative; and the 
event proved the accuracy of the first opinion. 
(Fodere, p. 460.) The same means, however, 
and others equally severe, have often been em- 
ployed without such a fortunate result, in equally 
suspicious cases. Examples of this sort, we have 

Vol. II 18 m* 



reason to know, were by no means extremely rare 
in the army and navy, duiing the late war. A 
melancholy instance of real insanity treated as 
feigned is related in Mr. Marshall's Hints to young 
medical Officers (p. 140) ; and we could enume- 
rate others of a similar kind which occurred in 
the navy. 

Some cases have come to our knowledge where 
deception was believed and punishment inflicted, 
yet, in which evidence of the reality of the dis- 
ease was most conspicuous. In one of these, 

which occurred on board H, M. ship , two 

circumstances ought at once to have opened the 
eyes of the surgeon, viz., the periodical recur- 
rence of the affection, and the total sleeplessness 
that prevailed during the paroxysm. They were 
also, we suspect, much less uncommon in civil 
life formerly, when the execution of the laws 
against vagrants was more summary than at pre- 
sent. 

In this, as in all other feigned diseases, im- 
pressing the impostor with the hopelessness of 
his attempt to succeed in gaining his object, 
will be found the most effectual means of putting 
an end to the simulation. A few words inten- 
tionally dropped in the patient's hearing, but as 
if incidentally, expressive of the expectation en- 
tertained by the medical attendant that the case 
would be cured, and of intended perseverance in 
the treatment then pursued, have often proved 
prophetic. We have known instances of a stop 
being almost immediately put to simulated mad- 
ness, by sending the soldier to the depot for the 
insane. 

It is fortunate that the very treatment most suit- 
able to the recovery of persons really deranged is 
that which is most intolerable to the impostor. 
None but the most determined characters will be 
long able to resist the horrors of solitary confine- 
ment, bread and water, and the constant pain of 
blisters and other counter-irritants. Seclusion is 
particularly necessary in all such cases, as nothing 
tends so much to keep alive the hopes and the 
courage of the impostor as the consciousness that 
his raving is heard by his fellows, and the belief 
that an impression favourable to his views may be 
made on the minds of his officers, by the contin- 
ued exhibition of his miserable state. 

30. Malformatloii. — Deformity, such as cur- 
vature of the sjjine, elevation of one shoulder, 
shortness or distortion of a limb, inversion of the 
feet, &c., are occasionally simulated by soldiers, 
and sometimes with so much success that they 
obtain their discharge on that account. It may 
be said that a man who feigned deformity would 
readily be exposed by a medical practitioner who 
is intimately acquainted with the healthy configu- 
ration of the human body. This opinion seems 
to be well founded, yet cases occasionally occui 
from which it would appear that a simulator of 
deformity is not easily detected. We are ac 
quainted with more than one instance where a 
board of medical officers have recommended re- 
cruits to be discharged from the army on account 
of alleged great deformity, but who were, in fac, 
remarkably handsome well-made men, and aftei- 
wards enlisted and were approved for service. 

31. Needles in the Body. — Among the \tt 
rious factitious disabilities, induced or voluntarilj 



idb 



FEIGNED DISEASES. 



submitted to by patients, the singular one of the 
introduction of needles into some part of the 
body deserves particular notice. The two fol- 
lowing cases will point out the character of this 
affection. 

In July, 1818, a young woman was admitted 
into Richmond Hospital, Dublin, on account of a 
painful swelhng of the left hand and arm, some- 
what resemliling that which occurs in phlegmasia 
dolens. The inflammation continued to increase, 
diarrhoea supervened, and her general health be- 
came greatly impaired from the constant pain and 
irritation of the disease. Amputation was per- 
formed close to the shoulder-joint, on the 21st of 
September. On examining the arm, eight or nine 
needles were found in ihe palm of the hand and 
forearm. The cause of the inflammation was 
now evident. This woman eventually confessed 
that she herself introduced the needles into her 
hand and arm, and she would assign no other rea- 
son for so doing but that she was tempted by the 
devil. An unwillingness to labour so as to pro- 
cure a livelihood seems to have lieen the efficient 
cause of her exciting inflammation for the pur- 
pose of being admitted into an hospital. For 
several years after her arm was amputated she 
was employed in Richmond Hospital as a servant. 
(Phrenological Journal, vol. ii.) 

The case of Rachel Hertz is perhaps still more 
remarkable. At about the age of fourteen, on 
the 16th of August, 1807, this woman became a 
patient of Professor Herholdt of Copenhagen. 
From this date until February, 1819, she suffered 
under a variety of anomalous complaints, and 
especially an affection resembling hysteria, or epi- 
lepsy, or both. About this time a tumour appear- 
ed near the umbilicus ; and being opened, a nee- 
dle was extracted firom it. From the 12th of Feb- 
ruary, 1819, till the 10th of August, 1820, a pe- 
riod of eighteen months, this wouian had a num- 
ber of abscesses formed in different parts of the 
body, from which two hundred and ninety-five 
needles were at different times extracted. Her 
superior and inferior extremities became paralytic, 
and continued so for a long period ; but she event- 
ually recovered. Swellings, or abscesses, contain- 
ing needles, continued to appear from time to 
time ; so that from the 28th of May to the 10th 
of July, 1822, one hundred were extracted, alto- 
gether amounting to three hundred and ninety -five. 
It was supposed by Professor Herholdt and Dr. 
Otto, that she had swallowed the needles during 
her paroxysms of hysteria or epilepsy ; but the 
truth was ascertained in a very simple manner. 
A young girl was observed in the act of introduc- 
ing needles under the skin of her arm ; and being 
asked who had taught her that trick, her answer 
was, that she had seen Rachel Hertz introduce 
needles under her skin. 

32. Opiithaluiia. — Factitious ophthalmia is, 
we believe, rare in civil life. It was very frequent 
among the French conscripts during the late war ; 
no fewer than twelve per cent, of the inefficient 
conscripts belonging to the department of the 
Seine, during a period of ten years, were rejected 
on account of " impaired vision — diseases of the 
eyes." During the first ten or fifteen years of the 
present century, inflammation of the eyes prevail- 
ul to a grea' extent in some regiments of the 



British army, and there is much reason for sup. 
posing that factitious ophthalmia was then fre- 
quent. The following is one of the most exten- 
sive instances of factitious ophthalmia that has 
come to our knowledge. In the year 1809, three 
hundred of the men of two regiments which were 
on duty at Chelmsford, became affected with oph- 
thalmia. The healthy men of the corps were re 
moved to another station, and the sick remained 
in hospital, but under military command. Infor- 
mation having reached their commanding officer 
that one of the nurses of the hospital was in the 
habit of going to a druggist's shop for the purpose 
of purchasing medicines, suspicions were excited; 
and in conjunction with the medical officer in 
charge of the hospital, he made a successful at- 
tempt to discover whether the men had any drugs 
in their possession which might be employed to 
excite inflammation of the eyes. Accommodation 
having been provided for about twenty-four men, 
the number contained in one ward, at midnight 
the officer made his appearance in the hospital; 
the men were roused from their beds and forth- 
with marched in a state of nudity to the new 
ward. The old ward was secured for the night ; 
and next day when the beds were examined, a 
number of small parcels of corrosive subUmate 
were found concealed. Means were taken to pre- 
vent a supply of this article, and in a very short 
time two hundred and fifty of the men had re- 
covered, and were then marched to their respec- 
tive corps. 

The means that have been known to be used 
by soldiers to produce ophthalmia, besides the above, 
are powdered alum, snuff, salt, lime, tobacco-juice, 
&c. ; also, mechanical irritation of the eye by 
hard bodies, extraction of the eye-lashes, &c. 
Presumptive evidence is, in general, all that can 
be obtained respecting the production of this dis- 
ease ; but many circumstances are calculated to 
excite suspicion in the situations where it is likely 
to exist. Among soldiers it has been found that 
the right eye has sulVered chiefly, because this is 
the important organ to a modern man of war. 
The extreme rapidity of the progress of the in- 
flammation in the factitious ophthalmia is often a 
guide to the real nature of the disease : it some- 
times reaches its acme in a few hours, a circum- 
stance never observed in the natural disease. It 
is much more difficult to detect the disease in a 
chronic state. It is not improbable that the de- 
struction of the eye among soldiers has been pro- 
moted by the large pension which government 
has allowed to those who are discharged on ac- 
count of impaired vision. Formerly every man 
who became blind of one eye was discharged and 
received a pension for life of ninepence per day. 
This usage is, however, amended in the new pen- 
sioning warrant; for it is there ordered that » no 
soldier shall be discharged for the loss of one eye, 
whether it be the right or left" This regulation, 
if put effectually in execution, will in all proba- 
bility lead to a great diminution of the prevalence 
of ophthalmia in the army. 

When the disease is once detected, the cure of 
it is obvious ; but much difficulty is often experi- 
enced in putting an end to it where it is merely 
suspected. When perfect seclusion cannot be ob- 
tained, as in the navy, a strait-waistcoat has 



FEIGNED DISEASES. 



139 



been used to prevent the patient tampering with 
his eyes. (Hutchhison, loc. cit.) 

33. Pain. — There is perhaps no morbid affec- 
tion more frequently feigned than this; among 
the disabilities assumed for the purpose of obtain- 
ing a mere temporary object, there is certainly no 
one so often met with. It is the usual resource 
of the worthless and mean-spirited among soldiers, 
sailors, and slaves, to obtain a few days' respite 
from labour. The vulgar see little in real disease 
but pain, or they at least look upon pain as the 
common symbol of disease; which they regard as 
somethin<^ superadded to and existing separately 
in the body. They constantly describe any chronic 
ailment as an entity ; " it goes here, it flies there, 
it works in the bowels," &c. These flying or mi- 
gratory pains are very common among soldiers 
and sailors, and are known by the cant name of 
" the all-overs " they are readily detected by a 
little art. If the surgeon listens attentively to 
the narrative, and begins to catechise his patient 
with apparent simplicity and good faith, he may 
bring him to admit the existence of any symptom 
however absurd, and thus to betray himself 

By the more cunning and more resolute the ex- 
istence of severe pain, fixed in some particular 
spot, is feigned with more success, and often in- 
deed with astonishing constancy. Many instances 
are recorded, and several have come to our own 
knowledge, where individuals have supported 
their assumed character for a long period, under 
every privation and much real suffering. A re- 
markable case of alleged pain in the mamma, in a 
female mendicant, is related by Lentin, (Beytraege 
zur ausubenden Arzneywissenschaft, Leipz. 1797,) 
which could only be admitted as feigned on the 
clearest evidence. This woman went so far as to 
solicit, and at length to obtain, the amputation of 
first one mamma and then the other ; and, not 
content with this, she afterwards wished one of 
her hands to be amputated on account of a similar 
pain, of which she alleged it to be the site. This 
woman was proved to be an impostor in respect 
of part at least of her alleged maladies ; and she 
was considered by Dr. Lentin and other compe- 
tent judges as equally so in regard to the pain. 
The following cases related by MM. Percy, Lau- 
rent, and Fodere, are remarkable examples of the 
same kind. 

A young man having been deceived by a re- 
cruiting officer, who promised that he should be 
made an ensign on his joining the regiment, formed 
the resolution of attempting to obtain his discharge 
by simulating disease. He complained of having 
a deep-seated pain in the left knee-joint, on ac- 
count of which a great variety of remedies were 
applied, including blisters and moxa. The leg 
became by degrees extenuated, and he was sent 
to the baths. At last, after being four years under 
medical treatment, he obtained his discharge. 
Upon leaving the hospital, some of his comrades 
accompanied him a little way on the road, whom 
he treated with wine ; and before they parted he 
took off the wooden leg he had worn for three 
years, and threw it into the fire, saying, at the 
same time, " they deceived me, and I in my turn 
have deceived them." 

A soldier came under Fodere's care in the hos- 
pital of Martigues, complaining of a violent pain 



in the left leg, which he represented as arising 
from his having slept on the damp ground. 
During a period of eight months the most severe 
and painful external applications were made, and 
medicines given internally without effect. He 
still continued in bed, being unable, as he said, to 
stand. The leg having become wasted from the 
repeated use of blisters and issues, and apparently 
shorter than the other, and he being moreover 
pallid and emaciated in consequence of the severe 
regimen to which he had been subjected, Fodere 
at length obtained his discharge. While waiting 
for this, however, he was one day detected march- 
ing without any assistance, and, being taken up, 
at last acknowledged the imposition. (Op. cit. 
p. 473.) 

Pains are also frequently feigned in the internal 
cavities of the body; and probably these may often 
be more easily detected than such as are alleged 
to have their site in the external parts, inasmuch 
as pains of a simply nervous character are perhaps 
of less frequent occurrence in the former situation, 
and pain depending on other causes will be accom- 
panied by other appropriate symptoms. Still it 
must be admitted that detection in cases of this 
kind is more likely to he obtained through means 
of collateral evidence than by the absence of posi- 
tive and sensible indications of disease. Every 
experienced practitioner has witnessed cases of 
most severe pa.n in almost every part of the body 
in persons who could not be suspected to feign ; 
and the whole history of that great and increasing 
class of diseases termed Neuralgias is but a melan- 
choly testimony in favour of the possibility of real 
pain being unmarked by any certain external signs. 
Too often, we fear, has the absence of symptoms 
in such diseases been the cause of great additional 
suffering to the victims of neuralgia in the public 
service ; and we cannot more emphatically im- 
press on the mind of the young medical oflicers 
in the army and navy the necessity of caution in 
such circumstances than by relating the following 
cases. 

A young soldier, under the care of Fodere, com- 
plained of violent pains in various parts of his body, 
now in one limb, now in another, in the chest, 
head, &c., unaccompanied by any other symptom. 
Considering these pains as fictitious, Fodere 
refused to give the man his discharge ; but he 
nevertheless died in the hospital without any new 
symptom. " After his death," says Fodere, " I 
anxiously explored, by means of the scalpel, all 
the old seats of the pains, but could discover no- 
thing, in the membranes, the muscles, the nerves, 
or the viscera ; and I was forced to believe that 
life had been destroyed by the long continuance 
of the pains. Since then," the author adds, '< I 
have often preferred rather to be too lenient than 
to run the hazard of being again unjust." (Med 
Legale, t. ii. p. 471.) 

A seaman on board one of His Majesty's shij's 
applied to the surgeon, complaining piteously ol 
a pain in his shoulder preventing the motions oi 
the arm. He could assign no cause for it, allcg 
ing that it came of itself and gradually increased 
to its j)resent violence. No external mark could 
be discovered, and it being suspected to have 
arisen from some slight strain, it was ordered that 
the part should be rubbed with a common licj 



140 



FEIGNED DISEASES. 



ment. This was continued for a fortnight with- 
out relief; blisters were then applied and kept up 
for another fortnight. There still appearing no 
external sign of disease, the surgeon, suspecting 
imposition, ordered the man to move his arm 
before him. The poor fellow hesitated, and, beg- 
ging to he spared, was allowed to rest for a few 
days, when the arm was forcibly moved by an- 
other person. It was in vain that the man en- 
treated them to spare him ; the surgeon, confident 
in his fancied knowledge, and resolved to punish 
what his nosology told him was imposture, 
ordered a rope and a weight of eighteen pounds 
to be brought; he was commanded to swing the 
one, or to bear from the other the punishment 
which his alleged crime deserved. He implored, 
he hesitated ; when the rope, laid on with no 
slight hand on his shoulders, made him seize the 
weight ; but scarcely had he freed it from the 
deck when he was forced by pain to throw it 
down. This scene was exhibited for some time, 
and sullen resentment at length getting the better 
of patience, gave additional force to the surgeon's 
opinion. The man was about to be returned to 
his duty, and to be punished as an impostor, 
when a fatal evidence appeared to testify against 
the sentence of his cruel and ignorant judges : a 
slight swelling shovced itself on the part with 
signs of fluctuation ; it was laid open, and puru- 
lent matter, to the extent of nearly two pounds, 
was discharged I In this case, which we know 
to be authentic, ignorance was as conspicuous as 
barbarity. Such a scene could hardly occur in 
these days, and we heartily trust it never may in 
those which are to come. (See Med. and Phys. 
Journ. for January, 1808, vol. xix. p. 1.) 

34. Paralysis. — Palsy is frequently pretended 
among mendicants, and it is also occasionally 
feigned in the army and navy. The pathogno- 
monic symptoms of palsy commonly involve some 
organic alteration, which it is scarcely possible for 
a man to simulate with success if his case be care- 
fully investigated by well qualified persons. The 
fact, however, that impostors have been successful, 
is a sufficient warning to medical practitioners to 
devote much attention to the examination of 
doubtful cases. Coche, a French surgeon, who 
has given much of his attention to feigned dis- 
eases, says, "la simulation de cette maladie 
(palsy) n'est que ridicule;" but experience has 
proved that, however ridiculous, it has often been 
successfully practised. Dr. Cheyne mentions sev- 
eral cases of this kind, in two of which the pre- 
tended paralytics evinced ludicrous proofs of their 
still possessing the use of their limbs immediately 
after they had succeeded in gaining their dis- 
charge. It ought always to be considered a very 
suspicious circumstance in a soldier or sailor if the 
loss of power is confined to a single limb, as the 
arm, as such a form of paralysis coming on in 
adults is extremely rare. In a case detected by Dr. 
Cheyne, his opinion of the disease being feigned 
was chiefly founded on the following considera- 
tions • because there coexisted no other signs of 
disease ; because the countenance indicated health 
and intelligence ; because the function of the brain 
was undisturbed, and all the senses were entire; be- 
cause paralysis of the arm is a complaint frequently 
feigned bv soldiers but verv rare in reality. 



Feigned paralysis has been frequently detected 
by subjecting the patient to a powerful electric 
shock. A case occurred in the New York state 
prison which resisted all medicines until this re- 
medy was tried. Upon receiving the shock the 
patient jumped up, ran into the hall, and asked 
for his discharge from the hospital. (Dunlop's 
Beck, p. 12.) Mr. Hutchinson detected an impo- 
sition of this kind in a sailor, by administering a 
dose of opium to the patient, and then tickling his 
ear during sleep ; to relieve the irritation " the 
paralysed hand was instantly raised to the ear, 
which he rubbed with no small degree of force, 
and then turned round upon his left side, dragging 
the bed-clothes over him w^th his heretofore use- 
less arm." Of course the discovery was complete. 
The editor of the journal in which Mr. Hutchin- 
son's essay first appeared mentions a similar case 
in a soldier detected by the same means : in this 
case the sound arm was previously bound down to 
the side, under pretence of thereby benefiting the 
disabled limb. (Med. and Phys. Journ. liv. p. 93.) 

Shaking palsy is simulated chiefly by mendi- 
cants. When the general health appears to be 
good, little attention need be paid to the shaking. 
For the diagnosis of this disease see the article 
Paralysis. 

35. Plitliisls* — It could scarcely have been 
imagined a priori, that a disease like phthisis, at- 
tended with such a complexity of symptoms, and 
marked by such conspicuous alteration of the ex- 
ternal parts, would have ever been chosen as a 
subject of the malingerer. The following extract 
from Dr. Cheyne, however, will show that this has 
really been the case ; and as this form of simula- 
tion has never come under our view, we shall con- 
tent ourselves with the remarks of this excellent 
observer : — « The soldier, not content with repre- 
senting one feature of consumption, will often 
undertake a perfect portrait of that disease, and 
this he will sometimes execute with great clever- 
ness. The thought would seem to strike him 
while in the hospital under treatment for catarrh, 
or recovering from fever accompanied with pulmo- 
nary irritation. His cure all at once seems sus- 
pended ; his food, he says, stuffs him, and he begs 
to be replaced on spoon or milk diet ; he coughs 
much at the period of the daily visit ; he sup- 
presses his cough for some time previously, so that 
if there is any defluxion, it may be expectorated 
at that period. He expresses a wish to be let 
blood or blistered for a pain of the chest ; begs for 
some medicine to relieve his cough; applies for a 
furlough ; in short, so well does he act his part, 
that unless the surgeon is very circumspect, he 
will discover, when too late, that he has been made 
a dupe of. (Loc. cit. p. 160.) 

It is needless to observe that a thorough ac- 
quaintance with all the phenomena of the real dis- 
ease will enable any one, who is on his guard, to 
detect an imposition of this kind. Auscultation 
will be, in such cases, a most powerful, and fre- 
quently an infalhble means of ascertaininc the 
truth. ^ 

36. Polypus of tlx^ Nose — This has been 
mutated by the matchless ingenuity of the French 
conscripts, by introducing the testes of cocks and 
hares kidneys into the nostrils. (Percy and Lau- 
rent, op. cit.) * 



FEIGNED DISEASES, 



141 



37. Pompholyx. — This affection of the skin 
is sometimes simulated by the application of blis- 
tering plaster. The imposture may often be de- 
tected by carefully examining the vesicles, as parts 
of the flies are apt to adhere to them. In a young 
woman who lately produced this afTection in order 
to retain her comfortable position in aji infirma- 
ry, this was the case ; and, upon examining her 
box, small fragments of blistering plaster were 
found secreted. 

38. Pregnancy. — An impregnated state of 
the uterus is sometimes pretended, to gratify the 
wishes of relations ; to deprive a legal successor 
of his claim ; to extort money ; to obtain a re- 
mission of labour; or to delay the execution of 
punishment. A medical practioner, who has to 
give an opinion on a doubtful case of pregnancy, 
would require to make himself intimately acquaint- 
ed with the signs of real pregnancy, and he ought 
especially to consult the best works on legal me- 
dicine. Auscultation promises to be the most suc- 
cessful means of discovering whether an alleged 
case of pregnancy be real or merely pretended. 
(See Auscultation.) 

Pregnancy is very frequently feigned by negro 
slaves in the West Indies with the view of ob- 
taining ease ; as masters are accustomed to indulge 
them, when pregnant, with repose from the se- 
verer kinds of labour. Besides the assumption of 
the sickness and other common symptoms of preg- 
nancy, they place pads on the abdomen to deceive 
the sight. When they apprehend a discovery, they 
pretend that they have had an abortion, and often 
speedily re-commence the same course of decep- 
tion. They know by experience that it is an easy 
matter to feign the early symptoms of pregnancy. 
A case of simulation of this kind, which was car- 
ried to a very refined pitch, was mentioned to one 
of the writers of this article by the gentleman on 
whose estate it occurred. A female, whose re- 
peated alleged abortions had excited the suspicion 
of the overseer, and who was assured that nothing 
short of ocular demonstration would obtain belief, 
had the ingenuity to mutilate and prepare a lizard 
so as to deceive her cunning inquisitor. This im- 
position, however, was afterwards completely de- 
tected. These pretended gravidas are occasionally 
locked up some months before the expected period 
of delivery ; and instances have been known where 
they have remained confined for many months 
after this period has passed. 

39. Prolapsus Ani. — This disease has been 
simulated by partially introducing into the anus a 
sheep's bladder or gut containing blood, leaving a 
portion externally to represent the prolapsed rec- 
tum. Ambrose Pare mentions a case of this kind ; 
and the authors of the article in the Didionnaire 
des Sciences Mcdicales another. 

40. Rhenmatism, LiumltagOt A'C. — This 
class of disabilities is frequently feigned by the 
members of benefit societies, and by soldiers and 
sailors when they wish to evade a particular duty 
or to procure their discharge. Rheumatism, when 
severe, is commonly marked by some functional 
derangement or organic alteration, which it is 
difficult to simulate successfully. With respect 
to soldiers and sailors they ought very rarely to 
be dischat;!;ed on account of alleged rheumatism, 
&c. &c. unless in cases where there is an obvious 



organic change, such as great extenuation of a 
limb or nodosity of the joint. As in the case of 
simple pain, it is often difficult to discriminate 
these fictitious cases of rheumatism from the real 
disease. Still an attentive observer will in most 
cases be able to detect the feigned disease. 

The following remarks by Dr. Cheyne on this 
subject are very judicious, and well deserving the 
attention of military and naval practitioners : — 
" Chronic rheumatism is distinguished by some 
disorder of the digestive organs, impaired appetite, 
a look of delicacy, a degree of pyrexia in the even- 
ing, yielding in the latter part of the night or early 
in the morning to perspiration. Some emaciation, 
wasting of the muscles of the affected limb, fulness 
of the veins, and puHy enlargement of the affected 
joint, take place. There is in general an increase 
of the temperature of the affected part. These 
symptoms are much infliienced by the state of the 
weather, and they in some degree yield at length 
to proper treatment ; whereas those who feign this 
disease usually retain their appetite and looks; 
have no diurnal return of fever, and.no inflamma- 
tory symptoms. They give a glowing account of 
their sufferings, alleging that they have entirely 
lost the use of the part affected, which seldom 
happens in genuine rheumatism. There is for the 
most part no adequate cause assigned for the com- 
plaint; no relief from remedial treatment is ac- 
knowledged ; and while real rheumatic affections 
are aggravated by damp, the impostor complains 
equally at all times." (Op. cit. p. 175.) 

41. Short Sight. — This being a state of 
vision easily feigned, and, when real, incapaci- 
tating the subject of it for the duties of a soldier, 
is one of the most common disabilities pretended 
by unwilling recruits. It is also assumed by sol- 
diers in order to obtain their discharge. During 
the operation of the French conscription, and 
particularly in the early part of it, before effective 
means of prevention were taken, short-sightedness 
was feigned to a singular extent by the young 
conscripts. In the department of the Seine, of 
every thousand conscripts who were exempted 
from service in consequence of disabilities, from 
the year 1800 to 1810 inclusive, fifty-eight were 
excused in consequence of being near-sighted. At 
last the alleged disability became so common that 
a law was passed forbidding men to be exempted 
on this ground ; and all such persons were ordered 
to be employed as pioneers, hospital-servants, &c. 
Besides being assumed where it does not exist, 
this defect can be produced by the habitual use 
of concave glasses ; and this practice was exten- 
sively adopted by the young men in France liable 
to serve. In short-sighted persons, the crow-feet 
wrinkles at the corner of the eyes are strongly 
marked, and there is an habitual frowning or 
knitting of the brows ; but these signs are by no 
means unequivocal. The surest tests are enforcing 
the employment of concave glasses suited to the 
exact degree of imperfection assumed by the simu- 
lator, and putting him to read a book quite close 
to the eye. If able to read a book in this position 
without the glasses, and unable to read with the 
proper glasses at a corresponding distance, we 
may be almost certain that the disability is feigned 
And yet even in this we may be mistaken. MM. 
Percy and Laurent mention a young Sohooicuatbter, 



142 



who, in expectation of bcin? some day drawn for 
the army, practised reading with all kinds of 
glasses beforehand, and when he was drawn he 
obtained his exemption without difficulty. When 
any doubt is entertained regarding the existence 
of this defect, the most advisable measure is to 
follow the example of the French government, 
and place the individuals in situations where long 
vision is less necessary. This disability is rarely 
fci'^ned by sailors, because, if real, it would not 
incapacitate them for the duties required of them. 

42. Somnolency. — Occasionally persons al- 
lege that they are unable to undergo any fatigue, 
and sometimes that they are incapable of muscular 
motion on account of a constant and irresistible 
sleepiness. Dr. Hennen has recorded a most ob- 
stinate case of this kind. (Military Surgery.) 
Another case is detailed in the Edin. Ann. Reg. 
vol. iv. The subject of this case was a soldier in 
the Somerset miUtia, and only eighteen years of 
age. He had been confined for desertion. From 
the 26th April to the 8th July, 1811, he lay in a 
state of apparent insensibility, and resisted every 
means which it was deemed advisable to attempt 
for the purpose of rousing him. These means 
consisted of thrusting snuff up the mostrils, elec- 
tric shocks, &c. &c. It was at last conjectured 
that the torpidity might be owing to a fall, where- 
by his head might have been injured, and the 
operation of dividing the scalp was performed for 
the purpose of ascertaining whether there was not 
a depression of the cranium. The requisite inci- 
sions were made, the scalp was drawn up, and 
the skull examined without a word of complaint. 
When the instrument destined to scrape the bone 
was applied, he once, and only once, uttered a 
groan. As this case seemed to be hopeless, the 
man was discharged and conveyed to his parents. 
Two days afterwards, he was seen two miles from 
home, cutting spars, and carrying reeds up a 
ladder. 

The following case of feigned somnolency, or 
loss of sense, is a good example of the obstinacy 
with which the symptoms of disease may be simu- 
lated for the purpose of avenging an injury, or to 
obtain unjust compensation. A clergyman hear- 
ing his wife and servant-maid disputing in the 
kitchen, went below, and interfered so far as to 
repel some rudeness offered by the girl to her mis- 
tress, which he did bj'' pushing her to one side. 
The girl fell against the dresser, either by accident 
or design, whereby she received a slight contusion 
over her eye. She then ran to the street-door, 
and told the people that she had been almost 
murdered by her master ; and to corroborate this 
assertion, she fell apparently into an epileptic fit. 
Shortly afterward she was conveyed, as one ex- 
piring, to an hospital, and the clergyman and his 
wife were dragged to jail. The windows of his 
house were broken, his furniture was thrown into 
the street, and an account of the dreadful murder 
cried over the whole town. The girl lay for ten 
or twelve days without showing the least sign of 
sense or recollection. Mr. Dease having been 
called into consultation, soon detected the impos- 
•ure, and the woman almost immediately disap- 
peared The terror and shame of being so puh- 
hely exposed made such an impression on the 
»riind of the clergyman that his life was brought 



FEIGNED DISEASES. 

~^nto the most imminent danger, and the expenses 
attending his confinement greatly injured his for- 
tune. (Dease's Remarks on Medical Jurispru- 
dence.) 

Somnolency is, however, a real disease, and 
may originate without any obvious cause as a 
symptom of other diseases, or from external injury. 
Persons whose minds are alienated will frequently 
remain in bed for several weeks together in a 
semi-comatose state, resisting every argument and 
entreaty. This fiict, and the following histories 
of real somnolency, will teach the medical officer 
to be extremely cautious in pronouncing any such 
apparent affection to be simulated. 

Rudolphi, when in Milan, in 1817, witnessed 
the case of a journeyman book-binder, nineteen 
vears of age, who was affected with a curious sort 
of sleepiness, in some degree resembling intoxi- 
cation. In Rudolphi's presence he fell asleep, 
although he still f«ntinued to fold sheets along 
with the other workmen. His eyes were shut, 
and when it was wished to excite his attention, a 
loud knock was given on the table, by which he 
was awakened, and then he answered questions. 
The voice of one of the workmen, who was his 
friend, excited bis attention, even when the tone 
was low. Upon being partially roused, he looked 
about with his eyes half open, and seemed to be 
aware of what was going on around him ; for ex- 
ample, when a sheet was purposely folded wrong 
and given to him, he appeared to be displeased. 
He wrote a note in Rudolphi's presence. His 
comrades used sometimes to lead him about when 
he was asleep, and to make him play at billiards, 
&c. ; but he did not recollect that he had been 
so employed after he awoke. When allowed to 
remain asleep for a few hours, he began to snore, 
nodding his head as many persons do when asleep. 

A strong and active hussar, after many an in- 
effective effort during eight months to rouse him 
from a state of somnolent listlessness and inatten- 
tion to his person and duties, was discharged from 
his regiment, being generally considered as a 
skulker. Being forwarded to Chatham, he came 
under the care of Dr. Burrell, of the 72d regi- 
ment, who, from an absence of every other symp- 
tom of disease, was at first led to adopt the same 
opinion. In the course of a week, however, some 
difficulty of articulation was discoverable, greater 
heaviness in his look and sluggishness in motion 
appeared, which in a few days ended in coma, 
convulsions, and death. On dissection, two tu- 
mours of a firm medullary structure were discover- 
ed, in contact with each other, one of the size of 
a pullet's, the other of a pigeon's egg, situated in 
the right hemisphere of the brain, and projecting 
considerably beyond its surface. (Dub. Hosp. 
Rpj). vol. iv. p. 138.) 

A seaman belonging to one of His Majesty's 
ships fell from a considerable height, and pitched 
upon his head: on examination, no fracture or 
depression could be discovered, the only mark of 
injury being a tumour of the integuments, which 
soon disappeared. From the moment of the acci- 
dent, however, the patient exhibited symptoms of 
coma, inattention to surrounding objects, &c ; 
and he was therefore bled largely, purged, &c. 
The soporose state continuing without any other 
marked symptom, and there being discoverable 



FEIGNED DISEASES 



143 



not the slightest inequality of the bone, or other 
local indication of any injury beneath, the surgeon 
began to suspect imposition, and had recourse to 
the most vigorous counter-irritation, by blisters to 
the head, &c., partly on account of the painful 
impression produced by these means. This man 
at length was invalided, and on his way to 
England was seen by the gentleman to whom we 
are indebted for this interesting history, in the 
Naval Hospital at Gibraltar. At this time he lay 
in a listless semi-comatose state ; rousing up when 
spoken to, opening his eyes and answering ques- 
tions very rationally. A very marked symptom 
in this case was the incessant action of the left 
hand in alternate flexion and expansion, a symp- 
tom which had come on immediately after the 
accident, and had never since left him by day or 
by night. When the hand was restrained he 
seemed more uneasy, and as soon as it was disen- 
gaged the motions were resumed. He was sent 
to some of the naval hospitals in England, and his 
subsequent history is not known until he came 
under the care of Mr. Cline in May 1800, in St. 
Thomas's Hospital. At this time, says Sir A. 
Cooper, he was in a great degree destitute of sen- 
sation and of voluntary motion ; his pulse was 
regular, his fingers were in constant flexion and 
extension. He had a depression near the supe- 
rior edge of the left parietal bone. Mr. Cline 
trephined him, removing the depressed portion of 
bone, and the man gradually and completely re- 
covered. (A. Cooper's Lectures, by Tyrrell, vol. i. 
p. 312.) 

43. Syncope. — A most disagreeable part of 
the duty of the medical officer is to attend at the 
corporal punishment of soldiers and sailors. On 
these occasions it is not rare for the culprit to 
feign fainting, in the hope of having his punish- 
ment remitted ; and the medical oflficer is some- 
times called on to decide. In other circumstan- 
ces, also, syncope is simulated by soldiers and 
sailors with the view of obtaining particular ends ; 
and it is occasionally the resource of the mendi- 
cant to impose on the charitable. 

Except in the extremely rare case of persons 
having a voluntary power over the action of the 
heart, there can seldom be any difficulty in dis- 
criminating the fictitious syncope firom the real. 
The total suppression of the pulse, or its great 
diminution in point of strength and volume, the 
coldness of the surface and of the perspiration, the 
paleness of the countenance, cannot be assumed 
at will ; and without these, the seeming exhaus- 
tion or alleged loss of muscular power will not im- 
pose on any person of experience. The state of 
the countenance alone suffices to indicate the real 
disease in almost every case. 

It is hardly necessary again to inculcate on the 
mind of the younf military or naval surgeon, tliat 
he must in all cases where the slightest doubt ex- 
ists, take the side of mercy. It is better that he 
should be a thousand times imposed upon, than 
that a fellow-creature should be punished while 
labouring under a severe disease, to say nothing 
of the risk of death occurring if the syncope is real. 

44. Swelled leg. (Barbadoes leg.) — Tume- 
faction of the leg is sometimes excited by soldiers 
putting a concealed ligature round the leg and 
lettinjr the limb hang over the side of the bed du- 



ring the night. There was a case not long since 
in Fort Pitt General Hospital, which was supposed 
by some of the medical officers nearly to resemble 
Barbadoes leg. This man had been sent home 
from India to be discharged. On admission into 
the hospital his thigh measured in circumference 
twenty-two inches and three-quarters, the calf of 
the leg seventeen inches and a half, and the ankle 
fifteen inches. Six days after the ligature had 
been discovered and removed, the thigh measured 
twenty inches, calf of the leg fifteen inches, and 
the ankle fourteen inches. Close examination 
will almost always detect the impression of the 
ligature in such cases, and the practice may be 
prevented by inclosing the limb in a box, or wrap- 
ping it in a marked bandage. 

4.5. Ulcers. — The formation or irritation of ul- 
cers by artificial means has been in all ages a fer- 
tile source of successful imposition to that class of 
persons who live by exciting the compassion and 
charity of the benevolent. In former times the 
more cunning and less daring vagrants imitated 
ulcers by fixing certain foreign substances on the 
skin, such as dry, shrivelled leaves, part of the 
skin of a frog, and even pieces of flesh. A curious 
case is quoted by Fodere from an old French sur- 
geon, Pigray, of a young woman who presented 
herself to the king of France to be touched for a 
large open cancer of the breast, but which, al- 
though " le mieux simule et contrefait qui se 
puisse voir," Pigray discovered to be a slice of spleen 
fixed on the mamma ! (Fodere, tom. ii.p. 486.) 

The actual formation of ulcers has been much 
more practised, and in the compulsory military 
service of all countries has been often carried to a 
very great extent. This was particularly the case 
during the late war among the French conscripts, 
and in the army and navy of this country. The 
most common site of these artificial ulcers, indeed 
almost the exclusive site in the army and navy, is 
the leg, a y)lace, no doubt, selected partly because 
their existence in that position efl'ectually incapa- 
citates the patient from military duty. These fac- 
titious ulcers are either formed entirely by art, or, 
which is the more common case perhaps, artificially 
aggravated into great and severe affections from 
slight sores occurring naturally, or from slight 
accidents. The means used to effect these objects 
are very various : vesicants, irritants, caustics, 
compression, friction, puncture, excision, &c. &c. 
Sometimes a portion of skin is cut out, and then 
some irritating substance, such as lime, arsenic, 
corrosive sublimate, tobacco, the skin of salted 
herrings, acids, &c. applied to establish the ulcer, 
after which it is kept up by milder kinds of irrita- 
tion. Mr. Hutchinson says, that the use of mine- 
ral acids is most difficult to detect. There was 
an old woman, who lived contiguous to the re 
cruiting depot at Dublin, who had the credit of 
carrying on a great deal of business in this way 
among the recruits. Her applications appeared to 
be a mixture of quick-lime and soft soap. But 
one of the most approved methods of operating i"* 
the firm compression of a copper coin against the 
tibia ; and we have reason to know that this was 
the most common practice in the navy. Copper 
has always enjoyed a great reputation as. acting 
injuriously on the animal body, and it is probable 
?hat this reputation has been the chief cautivi of it< 



144 



FEIGNED DISEASES, 



being emploj-cd to produce or aggravate ulcers, 
although its main effect depends on the mecha- 
nical impression produced by it. Mr. Hutchinson 
once found, in dissecting the leg of a sailor, which 
he had amputated for extensive caries of the tibia, 
a half-penny imbedded between the muscles, 
« nearly three inches from the margin of the ul- 
cer " and which the man confessed to have thrust 
into the ulcer nine months before. (Loc. cit. p. 
88.) Friction with sand seems also to have been 
extensively employed to produce ulcers; a process 
termed in the flash language <^ fox-hunting." 
(Dunlop, in Beck, p. 8.) An experienced eye 
will readily distinguish between an ulcer of recent 
formation asserted to be eld, and one really old ; 
but it is not so easy to discriminate one of long 
standing, kept up by repeated slight irritation, 
from a natural ulcer. In some cases after the es- 
tabhshment of the ulcer, so refined has been the 
imposition that a blister has been applied round it, 
with the view of producing the red glossy appear- 
ance possessed by the cicatrix of ulcerated parts. 
But the most distinguishing difference is the ready 
curability of the factitious ulcers, when secured 
from the tampering of the patient. 

When once a soldier or sailor is suspected of 
keeping an ulcer open, the obvious means of treat- 
ment are, seclusion if practicable, and defending 
the ulcer from injurious applications. The most 
common methods adopted by medical officers to 
effect this last object have been to seal the band- 
ages, or to inscribe on them, after they are applied, 
coloured lines drawn along the limb in such man- 
ner that it would be impossible to re-produce them 
if the bandage were removed and re-applied. 
Even these precautions have not always been 
found sufficient. Some of Mr. Hutchinson's pa- 
tients kept up mechanical irritation by means of 
pins thrust through the bandages. He was there- 
fore under the necessity of locking up the whole 
limb in a wooden box contrived for the purpose, 
and this he found an effectual remedy. 

46. Vomiting. — Some persons possess the 
power of expelling the contents of the stomach at 
pleasure, and thereby simulate disease of that 
organ. In 1S28, a soldier was for about six 
months in the General Military Hospital, at Dub- 
lin, on account of supposed disease of the stomach, 
chiefly indicated by a frequent disgorging of his 
food. About the end of that period it was ascer- 
tained that, instead of losing flesh, he increased 
in weight, a circumstance which was considered 
conclusive evidence that he did not suffer under 
any material disease. He was forthwith dis- 
charged from the hospital, and we have ascer- 
tained that he afterwards performed his duty effi- 
ciently. Vomiting became epidemic in the hospi- 
tal during tne time this man was a patient, but it 
ceased as soon as he was returned to his duty. 
Percy, in his article on simulated diseases, in the 
Dictionnaire des Sciences Medicales, mentions 
the case of a drummer who for a long time de- 
ceived the medical officer of an hospital by eject- 
ing the contents of his stomach. He could at 
pleasure regurgitate his food. In a quarter of an 
hour after he had swallowed soup, he used to re- 
turn the whole, apparently with great pain and 
general distress. It was eventually discovered 
inai he urivately purchased solid food, particularly 



hard-boiled eggs, which he did not vomit, and the 
imposture was thus detected. 

Mr. Hutchinson mentions a case of feigned, or 
rather of factitious vomiting in a sailor, which was 
produced by voluntary compression of the epigas. 
trium. The vomiting returned periodically, and 
upon the cause being discovered, was at once pre- 
vented by securing the patient's hands. Mr. 
Hutchinson adds, that he is thoroughly convinced 
of the existence of this power in certain persons 
to excite vomiting by pressure on the region of 
the stomach whenever they please. (Loc. cit.) 
Dr. Cheyne says that vomiting is voluntarily pro- 
duced by some persons by swallowing air and then 
eructating, in which process part of the content* 
of the stomach is brought up along with the re- 
turned air. (Dub. Hosp. Rep. p. 165.) We are, 
however, cautioned liy this distinguished physician 
not to be too hasty in deciding on the nature of 
vomiting in suspicious cases, as he himself con- 
fesses to have been in one case deceived by a pre- 
tended vomiting, and in another to have consi- 
dered a case of vomiting as feigned which eventu- 
ally proved fatal. 

47. Wounds. — These have often been feigned 
when they had no existence ; have been greatly 
exaggerated when slight ; and have been artifici- 
ally produced by the patient or with his concur- 
rence, in a very aggravated form. 

a. Fictitious wounds. — The pretence of being 
wounded when uninjured, or of being severely 
wounded when only slightly hurt, has ever been 
the resource and refuge of the coward in the day 
of battle. This practice has even been carried to 
such an extent as seriously to affect military ope- 
rations. CiEsar, in his account of the blockade 
of Utica, speaking of the wounded in a skirmish 
wherein the enemy were driven with great terror 
into their intrenchments before the city, says, 
" qui omnes, discessu Curionis, multique prseterea, 
per simiilationem vulnerum, ex castris in oppi- 
dum propter timorem se recipiunt. Qua re ani- 
madversa, Varus, et terrors exercitiis cognito, 
buccinatore in castris et paucis ad speciem taber- 
naculis relictis, de tertia vigilia silentio exercitum 
in oppidum reducit." (De Bell. Civ. lib. ii. 35.) 
In the official report of the capture of Tarragona 
by the French, in 1811, Count Contreras, the 
governor, complains of having lost a great many 
officers in the last defence by their hsiving feigned 
wounds, in order to avoid military duty. (Courier, 
July 30th, 1811.) "I have many times known," 
says Northcote, " cowardly lubbers during action, 
come tumbling down the ladder with the most 
violent groans and complaints, though, at the 
same time, they have received little or no hurt, 
and all I could do or say could not prevail on 
them to make a second trial of their courage, nor 
go up again till the action wa»all over. Nay, I 
have been told by those quartered at the same 
gun, that some dastardly fellows have actually 
put their feet or stood in the way of the carriage, 
on purpose to be hurt, that they might have a 
plausible pretence for going down to the doctor, 
which I must own I have great reason to believe, 
havnig sometimes met with such contusions in 
the legs and feet, occasioned (according to their 
own confession) by the carriage, but at the same 
time so slight as was scarce worth mentioning ; 



FEIGNED DISEASES. 



145 



though sometimes very violent, at other times 
there was scarce any injury or contusion to be 
perceived, notwithstanding the most grievous com- 
plaints of pain and uneasiness." (Northcote's 
Marine Practice of Physic.) Very distinguished 
men have had the meanness to simulate wounds. 
In one of his expeditions, Gustavus Adolphus is 
said to have pretended that he had received a con- 
tusion in the leg from a musket-ball, and, as a 
proof of the fact, exhibited a red spot on his leg 
and a corresponding blemish on his boot, which 
refused to receive the usual polish. (Hist. Sketch 
of the last Year of the Reign of Gustavus IV. of 
Sweden, p. 57.) 

One of the writers of this article was requested 
to visit an officer for the purpose of examining a 
gun-shot wound, which he alleged he had receiv- 
ed from the enemy in his left arm. Upon exam- 
ining the site of the wound, no injury could be 
discovered, except an abrasion of the cuticle, about 
the size of a large pea. The injury seemed to 
have been occasioned by a pen-knife rather than 
by a bullet. Care had been taken to destroy the 
sleeve of the jacket, so that it was impossible to 
learn any thing positive regarding the alleged 
cause of the wound by examining the clothes. 
Officers have been frequently accused of feigning 
wounds or contusions after a battle with the vievf 
of having their names recorded in the Gazette, 
or for the more sordid purpose of claiming a pen- 
sion. 

In a case of feigned wound without loss of 
continuity, which came under our own notice, the 
man had stained the part to represent the purplish 
yellow liue of ecchymosis on the decrease, alleg- 
ing that the contusion had been received some 
days previously. 

b. Factitious wounds. Mutilation. — The in- 
fliction of wounds by the individual, chiefly for 
the purpose of mutilation, is a practice which has 
prevailed in all ages and countries where military 
service has been forcibly imposed upon men. Mu- 
tilation was a frequent practice among the con- 
scripts of ancient Rome, more especially during 
the decline of the empire ; and it would appear 
that it is from the most common species of muti- 
lation among them, viz., by cutting off the thumb 
(pollicc/n truncando) that our modern word pol- 
troon is derived. At first this sort of mutilation 
exempted the individuals from service; but after- 
wards the law was altered, and in the prescribed 
levy from any district, two maimed recruits were 
only reckoned as one. Soldiers who voluntarily 
disabled themselves were branded and still retain- 
ed in the service. Mutilation was very frequent 
among the French conscripts during the wars of 
the Revolution and the Empire; and the same 
regulation was eventually adopted in France as 
among the Romans, viz., the retention in the ser- 
vice of all men whose mutilation could be proved 
to have been intentional. A species of mutila- 
tion very common among them was the extrac- 
tion of the incisor teeth, or the filing them down 
below the gum, a condition of parts which pre- 
vented the soldier from biting off the end of his 
cartridge in loading his musket. 

Mutilation has been very prevalent in the army 
and navy of this country ; and the modes in 
which it has been efTected have often been more 

Vol. II.— JO w 



than usually bold and severe. The wounds have 
frequently been inflicted during battle, or in a 
crowded barrack-room, with the view of giving 
greater plausibility to their alleged accidental oc- 
currence. Frequently, however, more especially 
in the navy, the act of self-mutilation has been 
openly practised. 

During the late war a naval officer went on 
board a merchant vessel at Yarmouth for the pur- 
pose of impressing seamen, and while on board 
said, jestingly, to a boy about ten years of age, 
that he would take him with some others; upon 
which the lad ran below, and immediately return- 
ed with one of the fingers of his left-hand cut 
off, exclaiming — " You can't take me now ! My 
father cut off three fingers that he might not be 
pressed, and I have done the same !" A seaman 
in the Ambuscade cut off his thumb in the pre- 
sence of his officers, in a sudden fit of anger and 
despair at being kept in the service at a time when 
some others were discharged : and several in- 
stances have come to our knov, ledge where sea- 
men cut off the whole or greater part of their 
hands, with the avowed purpose of obtaining their 
discharge. Others, again, who have committed 
similar mutilation of their persons, have pretended 
that they were done by accident. 

In many cases of mutilation the object of the 
men is two-fold, — to procure their discharge from 
the service, and to obtain a pension. The self- 
inflicted wounds of soldiers are most commonly 
produced by the musket, and they almost always 
pretend that they have been accidental. During 
the period of four years from 1824 to 1828, there 
were twenty-one soldiers pensioned in Ireland on 
account of injuries they had received in one of 
their hands by the explosion of their own mus- 
kets. Recent regulations in the army deprive 
soldiers of pensions who are disabled by such ac- 
cidents, except they occur in the performance of 
military duty ; and if the mutilation is proved to 
be intentional, the individuals are still retained in 
the service, although unfit for the ordinary duties 
of a soldier. Mutilation occurs in the army more 
frequently in the hands and fingers than in any 
other part of the body. In one regiment, how- 
ever, where the practice became so far epidemic 
that nine cases of mutilation by the explosion of 
muskets happened in the course of six weeks, the 
lower extremities chiefly suffered. V^-^e have known 
a number of cases of mutilation occur among sol- 
diers when they were on a visit to their friends ; 
and little doubt could be entertained that the maim- 
ing was voluntary. The injury commonly oc- 
curred about one or two days before the expira- 
tion of the furlough. 

Mutilation has been practised, but much more 
rarely, by parish paupers, with the view of obtain- 
ing immunity from labour. It has also occasion- 
ally occurred among slaves in the West Indies; 
but wc have been told that their animal courage 
is seldom sufficient to prompt such bold mea- 
sures. 

There will rarely, if ever, occur any difficulty 
on the part of the surgeon in detecting the impo- 
sition in the case of wounds being alleged to exist 
when no wound has been received. In the case 
of self-inflicted wounds or mutilation, however, it 
will not always be easy to prove that they have 



146 



FEIGNED DISEASES, 



been intentionally produced. The proof will rest 
eometiines on the nature of the wound, sometimes 
on the circumstances under which it is stated to 
have occurred, and sometimes on other collateral 
circumstances. In the case of a soldier or sailor 
it will often be a matter of grreat importance to the 
individual, that the decision come to is the true 
one ; as it will frequently have the effect of ob- 
taining for him his discharge from the service, and 
perhaps a pension, or of depriving him of both 
advantages, and perhaps entailing punishment 
also. In forming his opinion of the probability 
of the wound being self-inflicted, the surgeon will 
be guided by the consideration of the nature and 
extent of the wound, its situation, the nature of 
the alleged cause, &c. For instance, if the 
wound be of such a kind as renders it improbable 
that the patient either could or would have in- 
flicted it ; if it be of great extent and more than 
sufficient to effect the object the perpetrator may 
be supposed to have had in view, — if it be in a 
part of the body to which the patient's hands, or an 
instrument wielded by him, could not have reached, 
— the probability certainly is that it is accidental. 
On the other hand, if these circumstances are re- 
versed, and if the mode in which it is stated to 
have occurred is improbable or impossible, — if the 
alleged cause or instrument is ill calculated or not 
at all calculated to produce the effect, — the sur- 
geon will be more disposed to regard it as volun- 
tarily inflicted. The examination of collateral 
circumstances will often atlbrd more positive evi- 
dence than grounds of a merely medical kind. 
The following case affords an example of both 
kinds of evidence. A seaman on board one of 
His Majesty's ships lopped off two of his fingers 
with an axe upon a post, in the fore part of the 
ship termed the manger, and in the confusion of 
the moment left them there. He then ran down 
into the hold, and uttering a piercing cry rushed 
on deck, exhibiting his mutilated hand, and assert- 
ing that he lost his lingers by the accidental col- 
lision of two water-casks. Here the character of 
the wound sufficed to disprove the truth of the al- 
leged cause; — no collision of casks could produce 
so clear a wound, or so complete an amputation ; 
still more certain evidence, however, the man's 
own stupidity afforded ; for shortly after his two 
fingers were found on the manger, and lying near 
them the axe which had divided them. 

The improbability or even impossibility of a 
ivound being inflicted by the patient himself, is, 
however, no certain proo' that it has not been in- 
flicted intentionally ; snice the unhappy men have 
been known, like the ancient Romans, to assist 
each other in the perpetration of this partial sui- 
cide. Instances of this kind have been mentioned 
to us both in the army and navy ; the wounds be- 
ing produced both by fire-arms and cutting instru- 
ments. During the late war we remember an in- 
stance of a father cutting off one of his son's 
fingers to prevent him serving in the militia. 
There was a young convict on board the hulk 
for boys at Chatham, not long since, who placed 
his right arm over a space between two beds, and 
got a companion to strike the forearm with a long 
piece of wood. Both the bones were thus frac- 
tured ; and ever, after the arm had been put up in 



splints, he found means to displace the bones, and 
thereby prevented a perfect union. 

[See a table of feigned, pretended, simulated or 
excited diseases or disqualifications in the writer's 
Dictionary of Medical Science, 4th edit. p. 303, 
Philad. 1844.] 

In concluding this article, we cannot dismiss 
from our minds the possible impression it may 
leave on the minds of junior medical officers in 
the public service ; whom we would guard, on the 
one hand, if possible, from suffering a spurious 
humanity to be detrimental to the interests of the 
army or navy, and, on the other, with even more 
anxiety, from the vain desire of acquiring tempo- 
rary consideration by a stubborn and cruel incre- 
dulity, or by an affected shrewdness in detecting 
imposture where no imposture may exist. 

There are cases mentioned in the preceding 
part of this article, which show, indubitably, that 
the simulation of disease has frequently been prac- 
tised without the existence of any interested mo- 
tive, indeed without motive of any kind ; that 
there is, in short, a species of monomania of 
which this simulation is the characteristic. Such 
cases may occasionally be remembered with ad- 
vantage. 

But there is another consideration equally wor- 
thy of being entertained by all who do not wish 
the common feelings of a man to be lost in those 
of a mere disciplinarian. For notorious malin- 
gerers we are in no degree disposed to plead ; but 
when instances of deception become frequent, in 
any countr}^, in any garrison or station, in any 
regiment, or in any ship of war, the question may 
very reasonably present itself — is there not some- 
thing wrong in the arrangement of the place, in 
the government or administration of the particular 
portion of the community in which such frequent 
deceptions are resorted to; — something which, 
acting injuriously on the bodies or the minds of 
the men, is therefore not beneath the c!onsidcra- 
tion of the medical officers of the establishment, 
who alone can appreciate the mischief, and by 
whose mediation alone it is likely to be remedied ' 
The privilege conferred by their profession, of be- 
ing the fric;ids of mankind, is one which ought 
not to be willingly resigned. 

The negro-slave, and the conscript of an impe- 
rial conqueror, may be equally placed beyond the 
pale of such considerations; but the British sol- 
dier or sailor ought never to be so ; even the con- 
vict is not shut out from mercy. The condition 
of both soldiers and sailors has, during late years, 
been much ameliorated ; and deceptions are less 
frequent both in the army and navy than of old. 
These amendments in their condition have often 
arisen out of the representations of enlightened 
and humane medical superintendents. Wherever, 
therefore, we repeat, the instances of imposture 
are numerous, — wherever these manifestations of 
discontent are frequent among men whose gene- 
ral characters afford an assurance that in ordinary 
circumstances they would not jm-for pain and pri- 
vation to duty ; the circumstances in which such 
opposite and desperate resolutions are taken, 
should undergo the most scrupulous and fearles'i 
investigation. Such a duty is enjoined by ar, 



FEVER. 



147 



ftuthority higher than any temporary authority 
to whom its performance may happen to be disa- 

S^^'^"'- J. Scott. 

J. Forbes. 
H. Marshall. 

FEVER. — The word fever, derived from the 
Latin term febris (a derivative of the verb ferveo 
or /crieo, signifying to be kof,) is ai)plied to a 
class of diseases characterized by morbid heat of 
skin, frequency of pulse, and disturbance in the 
various functions. 

In the Greek language, the word Trupt^i'a (from 
T!vp, fire,) expresses fever ; hence the origin of 
the term pyrexiie, under which the ancient wri- 
ters comprehended fevers and bijlummatlons, a 
classification which has been retained by modern 
nosologists. It therefore appears that upon one 
symptom alone, increased heat, the nosological 
distinction of a very numerous and important 
class of diseases has been founded. Though this 
characteristic feature is very generally observed, 
nevertheless in some cases of fever, strictly so 
called, the heat of skin is not above the natural 
standard, sometimes even below it; from this 
circumstance, therefore, it is evident that other phe- 
nomena are necessary to constitute a febrile disease. 

We know so httle about the cause of the gene- 
ration of animal heat, that no satisfactory expla- 
nation of its increase or diminution in fever has 
been given : it seems probable, however, from 
some experiments, that its evolution is intimately 
dependent on the condition of the brain and ner- 
vous system, and until physiological investigations 
shall unfold with greater certainty the mode in 
which animal heat is generated, the pathologist 
must be satisfied with the ultimate fact, that in 
febrile diseases there is generally, among other 
phenomena, increased heat. 

There are some diseases, the symptoms of which 
are so characteristic, and so invariably present, 
that there is little difficulty in determining their 
precise nature and seat. The various organic 
inflammations — of the brain, lungs, intestines, 
&c. — are examples of this class : there are others 
of which the precise locality is either so varied or 
obscure, either as regards the symptoms during 
life, or, in many instances, on dissection after 
death, that we are unable to discover their nature. 
To this latter class fever properly belongs. It is 
true that in most cases of fever we can discover 
the existence of certain lesions, but these are too 
vague or indefinite to enable us uniformly to de- 
cide on the primary seat of the malady. It is 
more than probable that in what is usually called 
idiopathic fever there is alteration either of the 
solids or fluids, although its precise locality can- 
not in every case be detected ; but without disease 
in either the one system or the other, wc maintain 
that fever cannot exist. 

It is too generally imagined that the primary 
disease which induces fever is essentially local in- 
flammation. The application of this doctrine to 
the early stage of fever, we hold to be not only at 
variance with facts, but dangerous as to the prac- 
tical deductions to which it leads. We know that 
irritation, far short of inflammation, is sufficient 
to excite feverish indisposition, more particularly 
at those periods of life at which the vascular sys- 



tem is easily excited by apparently trivial local or 
sympathetic disturbance, (for example, in infancy 
or childhood by dentition or intestinal irritation,) 
and that this feverishness disappears when the, 
cause is removed. The paroxysm of an intermit- 
tent is induced by the peculiar eflect of a mala- 
rian poison ; in this disease, the whole phenome- 
na of fever are well marked, but certainly few will 
maintain that the febrile disturbance is the conse- 
quence of local inflammation. There can be lit- 
tle doubt that the error alluded to may in a great 
measure be imputed to the attempts to discover 
the cause or nature of fever in the various local 
lesions which are observed in fatal cases. 

On the other hand, the important fact should 
ever be kepi in view, that the primary disorder, 
whatever it may be, passes readily into inflamma- 
tion, and that the lesions which arise in the pro- 
gress of fever constitute the principal source of 
danger, and are in many instances the more im- 
mediate cause of death. 

If we trace the early records of medicine, we 
find that the nature of fever has afforded ample 
field for discussion from the time of Hippocrates 
to the present day. Both the solids and fluids 
have been investigated, and arguments adduced 
in support of the opinion, that a morbid condition 
of either the one system or the other was the 
cause of fever. 

The ancients possessing a very scanty know- 
ledge of anatomy, either in its healthy or morbid 
state, and the secretions being evidently vitiated 
in the progress of fever, it was natural that a mor- 
bid condition of the fluids should, in the early 
ages of medicine, be considered as its primary 
cause. The humoral pathology was accordingly 
received as the only explanation or theory of fever, 
for many centuries. We find the early medical 
writers entertaining the idea, that tlie system 
waged war against something noxious within 
itself, and that in the attempt to expel the offend- 
ing agent, a violent commotion was excited. By 
this plausible theory, the duties of the physician 
were restricted to assisting nature in her efforts to 
get rid of what was deemed injurious to the wel- 
fare of the body : in fact, fever was imagined to 
be a natural and salutary process, indispensably 
necessary to throw off whatever was noxious, 
whether generated within the body, or introduced 
by external causes. Some theorists, in their anx- 
ious desire to support this doctrine, endeavoured 
to deduce the term fever from the Latin verb feb- 
ruare, signifying to purge or purify, and by those 
who implicitly believed in this theory, the deriva- 
tion was no doubt considered apt and appropriate. 
The application of the doctrines of the humoral 
pathology in explanation of the phenomena of 
fever, received much apparent confirmation from 
the circumstance, that in eruptive fevers, after 
more or less febrile disturbance, various eruptions 
appear on the skin. It was rendered still more 
imposing, when the chemical doctrines of Para- 
celsus and Van Helmont were first promulgated. 
These chemical philosophers imagining that in 
fevers the fluids possessed at one time an alkaline, 
at another an acid quality, conceived that an eflex 
vescence took place, which gave rise to a febrilo 
paroxysm — an assumption which led to not a few 
fatal practical errors. 



148 



FEVER. 



The idea that particular forms of fever depend 
on a morbid state of the fluids has been main- 
tained bj many pathologists in more recent times. 
The vital fluid has been subjected to chemical 
analysis with the object of ascertainmg the com- 
parative difference in its component ingredients 
during fever: these researches tend to show, that 
previous to the attack, the blood is materially 
altered in its properties, and that its constituent 
principles undergo progressive changes, as the 
disease proceeds. 

This department of chemical pathology has 
been lately much elucidated by the experiments 
of Dr. Cluny, detailed in his published lecture on 
typhus fever, and also by the observations of Dr. 
Stevens, who states that on opening the heart in 
fatal cases of yellow fever, he found, instead of 
blood, a dissolved fluid nearly as thin as water 
and black as ink. In both sides of the heart the 
fluid was equally black, and throughout the vas- 
cular system all distinction between venous and 
arterial blood was completely lost. Dr. Stevens 
supposes that when the blood is found in this 
state, it is entirely deprived of its stimulating 
properties, and therefore unable to excite the heart 
or to support life. It is affirmed, also, that the 
changes in the blood take place in a certain deter- 
minate order. It first loses its solid parts and be- 
comes thin ; it is then deprived of its saline prin- 
ciples, and becomes black and vapid ; and lastly, 
from its preservative elements being destroyed, it 
loses its vitality so as to be incapable of support- 
ing life. 

Dr. Stevens considers this diseased state of the 
blood as the first link in the chain of the morbid 
phenomena which constitute fever. He believes 
that the aerial poisons from which all pestilential 
diseases arise are attracted with the atmospheric 
air into the circulation, mix directly with the 
blood in the pulmonary system, and that this 
poisoned or diseased state of the whole circulating 
current is the cause of the subsequent morbid 
action in the solids. Similar views with respect 
to the pathology of fever are gaining ground in 
France, in which country the doctrines of solidism 
have almost exclusively prevailed. 

The study of the structure and functions of the 
human body, in its healthy as well as in its mor- 
bid state, being the most satisfactory method of 
investigating the nature of disease, and lesions 
having been discovered in various organs of those 
who have died of fever, the attention of patholo- 
gists has in later times been directed to the state 
of the solids, in hope that the origin of fever might 
be discovered. 

The locality of the disease, however, has been 
most warmly disputed ; indeed there are few 
organs of the body which have not been fixed on 
as the seat of fever ; from which it may be in- 
ferred, that the doctrines of solidism are as little 
likely as those of the humoral pathology, to ex- 
plain every variety of this inscrutable disease. 

The functions of the brain being almost inva- 
riably affected in fever, it was to be expected that 
the solidists would endeavour to trace its origin to 
t\v nervous system. We accordingly find, that 
towards the close of the seventeenth century, Stahl 
maintained that the phenomena were the result of 
a general commotion in the system, in its en- 



deavour to throw off a spasm induced by torpor 
of the brain and nervous system. This explana- 
tion, which, after some modifications, was adopted 
by Hoffman, was the first attempt to assign to the 
brain an important share in the pathology of this 
disease. It formed the basis of the theory in- 
vented by Cullen, who believed that in fever cer- 
tain causes produced collapse or diminution of the 
energy of the brain. The effect of this on the 
voluntary muscles and the extreme vessels was 
universal debility, and spasm or constriction of 
the capillaries : the subsequent re-action of the 
sanguiferous system, however, had the effect of 
resolving this supposed spasm, and consequently 
removing the fever. The prominent importance 
the Edinburgh Professor assigned to the fictitious 
debility which was imagined to result from this 
unknown condition of the brain, notwithstanding 
his theory that there was an inherent protective 
power in the system by which this fancied weak- 
ness was to be overcome, has been followed by 
serious practical errors, by abstracting the young 
and inexperienced mind from the more acute 
forms of fever, and from those important local 
complications which very frequently take place in 
its progress. Besides, as Dr. Parr has remarked, 
in this system the production of spasm by debility 
is an isolated fact without a support, and the in- 
troduction of the vis medicatrix naturse is the 
interposition of a divinity in an epic, when no 
probable resource is at hand. 

It is evident that in the definition of fever giver, 
by Cullen in his nosology, he expressly discoun- 
tenances the idea of primary local disease; con- 
sequently he only partially adopted the doctrine 
of solidism, his theory merely implying that the 
various exciting causes act primarily on the brain. 

This doctrine prevailed not only in British but 
in many continental schools, till Dr. Brown, evi- 
dently to gratify a feeling of resentment, opposed 
it with great bitterness. He invented and pub- 
licly propounded with much plausibility an oppo- 
site theory, which had the merit of great simpli- 
city- According to Brown, the living system is 
an organized machine endowed with an inherent 
principle of excitability, arising from a variety of 
internal and external stimuli, and from which the 
excitement which constitutes the life of the ma- 
chine is maintained. Upon these principles he 
founded the character and mode of treatment of 
all diseases, which were supposed to consist but 
of two families, the sthenic and the asthenic ; the 
former produced by accumulated, the latter by 
exhausted excitability, and marked by indirect de- 
bility. The remedial plan was as simple as the 
arrangement. Bleeding, low diet, and purging 
were employed to cure the sthenic, and stimulants, 
of various kinds and degrees, the asthenic diseases. 

Fevers, therefore, under this hypothesis, like 
other diseases, are either sthenic or asthenic, as 
they are the result of accumulated or of exhausted 
excitability. This doctrine obtained but few ad- 
herents in the British schools, though, as we shall 
presently notice, it prevailed extensively for a 
time in several parts of the continent, more par- 
ticularly in the north of Italy. 

Another class of solidists asserted that inflam- 
mation of the brain was the cause of fever. 
1 Ploucquet, who appears to have first taken this 



FEVER. 



148 



view, admitteJ, however, that from particular cir- 
cumstances, other organs became occasionally im- 
plicated. Though this theory evidently implied 
that fever was dependent on local inflammation, 
it gave the disease a wider range — it assumed in- 
flammation of the brain to be the source of fever, 
but that from the operation of certain causes, other 
irritations were in some instances superadded. 
Marcus and Clutterbuck have subsequently adopt- 
ed this view, and have severally adduced argu- 
ments in its favour. Admitting, however, that 
the various exciting causes of fever do in some 
instances exert their action on the brain, we have 
no evidence that they produce, in the first instance, 
inflammation in this organ : on the contrary, the 
symptoms denote that the nervous system has 
only received a peculiar and powerful impression. 
When, on subsequent re-action taking place, a 
general impulse is given to the circulation, and 
the nervous system is roused from its depression, 
inflammation of the brain does frequently take 
place, especially in young plethoric subjects, just 
as it may supervene in any other organ to which, 
from causes hereditary or acquired, the individual 
may be predisposed. It should also be impressed 
on those who are inclined to adopt this doctrine, 
that although in a considerable proportion of per- 
sons who die of continued fever, the membranes, 
and frequently the substance of the brain, bear 
unequivocal marks of inflammation, yet such 
morbid appearances are by no means invariably 
observed. 

We are next to advert to the doctrine which as- 
cribes the phenomena of fever to primary affection 
of the intestinal canal. Lesions of the intestines 
in fatal cases of fever had been long ago pointed 
out by those who devoted much attention to the 
study of morbid anatomy. Bonetus stated that 
on dissection of persons who died of malignant 
fever, he found the stomach and intestines inflam- 
ed. Bartholinus made a similar observation ; and 
in the works of Sydenham, allusion is made to 
ulceration of the intestines in continued fever. 
Subsequently Roederer and Wagler (De Morbo 
Mucoso, Goettingffi, 1762) published a description 
of an epidemic mucous fever which prevailed at 
Gottingen, in which the appearances which were 
found after death in the alimentary canal are mi- 
nutely detailed. 

From these statements, it appears that the 
morbid appearances in the alimentary canal had 
attracted the attention of pathologists long before 
the promulgation of the theory in France, that 
fever was the result of inflammation of the mucous 
membrane of the intestines. This view, which 
was first maintained by Broussais more than 
twenty-five years ago, has become the prevailing 
opinion in France, though it has gained compara- 
tively few proselytes in other countries. (Examen 
des Doctrines Medicales et des Systemes de No- 
sologic, &c. Par F. J. v. Broussais. Prop de 
Mud. cxxxviii. cxxxix. 

Those who maintain the physiological doctrine 
of Broussais, contend that fever is entirely symp- 
tomatic of irritation or inflammation of the mucous 
membrane of the intestines. The leading principle 
of this theory is, that every irritation which is 
capable of producing an impression on the brain 
is reflecte'' by this organ on the mucous mem- 



brane of the bowels. Broussais applies it to other 
acute diseases ; for instance, in small-pox or 
measles, the inflammatory excitement by which 
they are accompanied is supposed to be first con- 
veyed to the brain, and afterwards reflected on the 
mucous membrane of the intestinesi, and that thus 
inflammation (gastro-enterite), the supposed cause 
of these eruptive fevers, is produced. 

It is affirmed that inflammation and its conse- 
quences are invariably found in the mucous lining 
of the intestines, on examination of persons who 
have perished from fever, and that the treatment 
which is founded on this view is the most success- 
ful. Broussais, indeed, asserts with unparalleled 
boldness, that the tables of mortality declare in 
favour of the new doctrine, and that its influence 
on the population would be more favourable than 
vaccination itself. 

Though Roederer and Wagler, Prost, (La Me- 
decine eclairee par I'ouverture des Corps), Baillie, 
(Morbid Anatomy), and others, had previously 
delected morbid appearances in the bowels, in 
their dissections of persons who had died of fever, 
the theory of Broussais, that inflammation of the 
mucous membrane of the intestines is the cause 
of fever, had the eflfect of directing the attention 
of pathologists still more particularly to the condi- 
tion of the intestines in this class of diseases. In 
1813, M. Petit and M. Serres* published the ac- 
count of a disease, very frequent in Paris in 1811, 
1812, and 1813, which they called entero-mesen- 
teric fever, and which was characterized by all the 
symptoms of continued fever, but originated appa- 
rently in certain changes in the inferior portion 
of the small intestines and ileo-caecal valve, ac- 
companied with enlargement and suppuration of 
the corresponding glands of the mesentery. The 
precise anatomical lesion of the intestines, how- 
ever, was not ascertained by these laborious patho- 
logists, but subsequently by M. Bretonneau of 
Tours,! who, after investigating the subject with 
great minuteness, came to the conclusion that the 
primary source of fever was in the conglomerated 
mucous follicles, or glands, situated in the lower 
portion of the ileum and solitary glands of the 
cfficum. 

A most full and elaborate work has been lately 
published by M. Louis,^ in which the pathological 
views of Petit, Serres, and Bretonneau, as to the 
primary seat of fever, are confirmed. This author, 
moreover, has given a most minute account of 
the various secondary lesions which supervene on 
this supposed primary intestinal disease. 

These views of the nature of fever now prevail 
almost exclusively among the French pathologists. 
Mild fever is supposed to arise from gastro-enteritis 
alone, the various forms which it occasionally 
assumes being regarded as gastro-enteritis, with 
particular complications. For instance, inflamma- 
tory or ardent fever (a form rarely observed) uii 

* Traite (ie la Fievre Ent6ro-Meseiiterique ohservfee, 
reconiiiie, et signalee publiqiiemeiit a I'Hotel Dieu de 
Paris dans les ann6esl8]l, 1812, et 1813, par M. A. Petit, 
I'uti des M(idecins du dit Hopital, compose en partie par 
E. R. A. Serres, &c. 

f Trousseau, de la Maladie a laquelle M. Bretonneau 
a donnS Ie nom de dothin-ent6rite. Arch. G6n. de Med. 
X. 67. 1826. 

X Rpcherches Anatomiques, FathoHogiques, et Th6ra 
pcutiques sur la Maladie coiinue sui les noras de Giastrn 
Eaterite, &c. par P. Ch. A. Louis, M. D. 



150 



FEVER. 



ports an intense degree of this lesion ; t'ne adynamic 
(typhus mitior) is regarded as gastro-enteritis 
which has assumed such a degree of intensity that 
the general powers decline, while the intellectual 
functions are more or less disturbed. The more 
malignant forms of fever (typhus gravior) are 
supposed to be gastro-enteritis complicated with 
irritation of the brain, from sympathy with the 
state of the alimentary canal ; and when fetor of 
the breath, perspiration, and stools are observed, 
the disease becomes what has been termed putrid 
fever, — that is, putrid symptoms are superadded to 
the primary gastric inflammation. 

It cannot, however, be conceded that in every 
form of fever this local disease does exist, as it has 
not been universally, nor even in the majority of 
instances, discovered on the most minute exami- 
nation of the intestines in fatal cases. The more 
probable inference is, that this gastro-enterite, or 
follicular disease, occurs only occasionally, and 
that it is much more common in some places than 
in others. We know that it is observed more 
frequently in the fevers of France than in those 
of Britain ; very rarely, if ever, in the epidemic 
fever of Ireland ; and that it is only occasionally 
met with in the epidemic visitations in the northern 
districts of England and Scotland. 

From its being observed in a greater proportion 
of cases in London and Manchester, it is probable 
that there are some local causes or circumstances 
in particular places, which produce this intestinal 
affection. Whether in those cases in which it has 
been found after death, (for we maintain that the 
pathognomonic or diagnostic symptoms by which 
it has been supposed to be indicated are by no 
means uniform or satisfactory,) it be the cause or 
effect of the febrile symptoms by which it is ac- 
companied, is still a question about which there 
is great difference of opinion, though the majority 
of British physicians regard these intestinal lesions 
as only the sequeloB or consequences of fever. 

[Of late years, many of the French, and some 
of the American, pathologists have maintained, 
that the intestinal follicular lesion, referred to 
above, is characteristic of one form of continued 
fever — the typhoid. To this view reference will 
be had hereafter. It is not uncommon in the 
United States. Dr. Bartlett (^Hisfori/, Diagnosis, 
and Treatment of Typhoid and of Typhus Fever, 
&c. p. 86, Philad. 1842) considers the red-tongue 
fever of Kentucky to belong to it.] 

The assertion that the treatment founded on 
the gastro-enteritic pathology is the most success- 
ful, is only an assumption ; indeed, it may be 
fairly inquired how many hundreds annually sur- 
vive the treatment calculated to increase gastric 
inflammation — how many are daily stimulated 
with bark, wine, and ammonia, and yet recover 1 
Besides, how can this doctrine be applied in ex- 
planation of the phenomena of intermittent fever? 
In France as well as in this country, periodic 
fevers are successfully treated by stimulants — 
bark, and even arsenic ; not to allude to the com- 
plete suspension of the febrile paroxysm for twen- 
ty-four, forty-eight, seventy-two hours, or even 
longer. 

These circumstances, when duly weighed, must 
:n our opinion disprove the general conclusion, 
lh«« pvery form of fever is the result of gastric 



inflammation. On the other hand, we are bound 
to admit the occasional existence (more frequent 
in some localities than in others) of the various 
intestinal lesions, which have been so minutely 
and elaborately described by the French patholo- 
gists, to whom, if this discovery be not entirely 
due, the merit must be conceded of having, with 
indefatigable labour, followed up the few hints 
which previous writers had thrown out, and thus 
brought to perfection one of the most important 
pathological facts connected with the morbid ana- 
tomy of fever. 

The celebrated Pinel took a more extended 
view of the nature of fever than any preceding 
writer of the continental school. He distinguished 
symptomatic from primary or essent'al fevers, and 
comprehended under this latter class, acute dis- 
eases in which there is a quick pulse, hot skin, 
and disorder in the various functions, the symp- 
toms being independent (as he supposed) of local 
disease. While he admitted, however, in his 
classification, the existence of fevers without pri- 
mary disease in any organ, he evidently localised 
the varieties when he stated that the seat of in- 
flammatory fever {angeio-tenic) was in the organs 
of circulation ; that the origin of bihous fevers 
(^meningo-gasfric) was in the mucous membrane 
of the intestines ; that a particular form of gastric 
fever (^adeno-meningeal) depended on disease of 
the mucous follicles alone ; that in another variety 
(iitaxic') the brain and nervous system were chiefly 
affected ; another type (^udynainic') being charac- 
terized by great prostration or depression of the 
vital powers, and often complicated with symp- 
toms which have been usually referred to pu- 
tridity. 

These views have been since partially adopted, 
and have evidently given origin to the doctrine 
entertained by a large proportion of physicians of 
the present day, that fever is an essential disease, 
that is, the symptoms are independent of primary 
organic lesion ; though it is admitted that in the 
majority of cases, local inflammations become de- 
veloped in its progress, and constitute the principal 
source of the severity or danger of the disease. 

The doctrines of Brown, which had obtained, 
as we have stated, comparatively few converts in 
his own country, made a strong impression in the 
north of Italy. Rasori, who had visited the medi- 
cal school of Edinburgh, was so enamoured with 
the Brunonian system, that, on his return to Italy, 
he published a compendium of this system, (to 
which the learning and ingenuity of Darwin had 
given a new impulse,) as well as a translation of 
the celebrated Zoonomia of Darwin. 

A few years afterwards, however, a petechial 
fever appeared at Genoa, in which the stimulating 
treatment recommended by Brown was evidently 
so injurious, and positively fatal, as to induce 
Rasori to reconsider the theory. He then became 
convinced of its inconsistency and error, and ulti- 
mately acknowledged this conviction in an account 
which he published of the epidemic of Genoa. 
(Storia della Febre Petech. di Genoa. Del Prof. 
Giovanni Rasori.) This epidemic, from whatever 
causes it arose, had many of the characters of 
what Brown termed an asthenic disease, and was 
consequently treated by stimulants. From thf 
numbers who perished under this plan, and from 



FEVER. 



151 



observation of its symptoms and progress, during 
which local inflammations not unfrequently oc- 
curred, Rasori was induced to substitute a modi- 
fied antiphlogistic, or, according to the language 
of the Italians, a cuntro-stiniulant treatment. 

Bloodletting in the commencement of the dis- 
ease, when the patient was young and vigorous, 
and when the symptoms demanded it, was found 
decidedly beneficial ; and in less severe cases, saline 
purgatives, antimonials, (more especially the tartar 
emetic in liberal doses) and acidulated drinks were 
employed. 

These remedies, with blisters in the advanced 
stage, stimulating friction to the abdomen, with 
the view of allaying the gastric irritation, hght 
bed-clothing, and rigorous diet, constituted the 
treatment employed in the epidemic. 

This change of Rasori's opinions produced a 
considerable sensation, and had the efiTect of over- 
turning the leading principles of Brown's system 
in Italy. The professors in the north of Italy, 
who were formerly attached to Brown's views, 
taught the doctrines of Rasori with some unim- 
portant modifications, and ultimately several works 
emanated from the different universities, explain- 
ing the leading principles of the " Doctrine of 
Contro-stimulus," or, as it was afterwards termed, 
the " New Medical Italian Doctrine." As it would 
lead to digression, we must refer those who wish 
to obtain information on the Italian doctrines to 
the several works alluded to.* 

Tommasini, whose learning and reputation rank 
him as a leading authority of the Italian school, 
considers fever to be the immediate result of a 
morbid condition of some internal organ ; and in 
this he is followed by a large majority of the Italian 
physicians. 

Others, however, adopt the views of Rubini, 
and ascribe the phenomena of fever to the effect 
of a contagious principle absorbed into the circu- 
lation, which, after producing inflammatory action, 
gives rise to symptoms indicating failure of the 
powers of the system. The antiphlogistic treat- 
ment is consequently pursued in the commence- 
ment of the fever, and afterwards a stimulant plan, 
when the powers of the system appear to give way. 
The doctrines of Broussais have obtained an 
inconsiderable number of adherents in Italy, so 
that we find the views of this celebrated patholo- 
gist much more generally received in France than 
in any other country. 

In our opinion, both essentialists and localists 
have taken a much too limited view of the etiology 
of fever. It appears to us that fever, whatever be 
its form, depends on some modification of one or 
other of the elements which enter into the compo- 
sition of the human body, or in other words, that 
it follows as a consequence of a morbid condition 
of either the solids or fluids. 

We know that, when the function of any organ 



♦Prima LineiB Materi<E Medicae, Aiictore Syrus Borda. 
—Delia Nuova Medica Italiana, Proluzione alle lezione 
di Cliiiica IVIedica nella P. Universita di Bologna per 
I'aniio Schnlastico, 181I)-18I7. Del Profussore Giacomo 
Trtniinasiiii — Dell' liiflaminazione et dclla Febre Con- 
tiiiua ; coiisiderazioiii Patologico-Pratiche. D. G. Tom- 
masini, Pisa, 18iO.— Del Metodo di curare, &c. Del Pro- 
fess. Giacomo Tommasini. Bologna, 1821. — Lezioni di 
Terapea Sjieciale siille Inflammazioiie, e Rendiconto 
Clinico, di V. Mantovani, Pavia, 1820. — Instilutiones 
Patliologicaf. Auctore F. A. Fanzago. 



becomes seriously disturbed, more particularly if 
inflammation arise, fever is induced. It is proba- 
ble that the various external causes, terrestrial or 
atmospheric poisons for example, induce fever by 
their action on particular parts, in the same way 
as the different poisons are known to affect par- 
ticular structures. On this principle the symp- 
toms peculiar to some epidemics may be explained ; 
for instance, catarrhal fever, in which the mucous 
membrane of the air-passages is affected ; or gas- 
tric fever, in which a peculiar impression seems to 
be made on the mucous lining of the intestines. 

We shall endeavour to show, in treating of the 
pathology of the fluids, that the blood is not only 
materially changed in fever, but that the diseased 
state prec'edes the attack, and that the changes 
take place in a determinate order. This view is 
corroborated by Andral, who states " that the fever 
termed injlammutory seems often to arise from 
no other source than the blood being too rich in 
fibrine ; in like manner, an impoverished state of 
the blood, whether accidental or natural, is often 
connected with mucous fevers, and with those 
characterized by a sudden sinking of the vital 
powers ; and that the source and primary seat of 
typhous fevers, properly so called, is proved to be 
in the blood, inasmuch as they are caused by the 
introduction of deleterious substances, such as ani- 
mal or vegetable effluvia, into that fluid." 

It is in this way only, by the blood becoming 
contaminated, and in this state circulating through 
the system, that fever can be supposed to be, ac- 
cording to the language of Dr. Fordyce, " a gene- 
ral disease which affects the whole system, the 
head, the trunk of the body, and the extremities ; 
the circulating, absorbing, and nervous symptoms; 
the skin, the muscular fibres, and the membranes; 
the body, and likewise the mind." (Dissertations 
on Fever.) 

When putrid substances are injected into the 
blood of the lower animals, this fluid loses its 
power of coagulating, and acquires a rapid ten- 
dency to decomposition : great sensorial disturb- 
ance, convulsions, delirium, hurried breathing, and 
bloody exhalations also take place, followed by 
speedy death ; and if the poi.son injected be highly 
concentrated, the animal is almost instantly de- 
stroyed. 

The effects which follow from the use of food 
of an unwholesome quality, or from an insufficient 
quantity of food, are probably owing to the changes 
which the blood undergoes from these causes ; 
hence scarcity may act both as a predisposing and 
exciting cause of fever. In this way, the origin 
of the disease in times of general distress among 
the poor is readily explained ; and the history of 
epidemic fevers in Britain .shows the intimate 
connection that has always subsisted between 
scarcity and fevers of a low or malignant type. 

It is also extremely probable, that in fevers 
which are produced by living in an impure atmo- 
sphere, the blood becomes the medium by which 
the morbific matter is circulated through the sys- 
tem. To prove the effect of putrid emanations on 
the animal economy, Magcndie confined a healthy 
dog in a situation which exposed him to putriu 
miasmata. For the first four days there was no 
change ; he then began to emaciate, and died much 
extenuated within six. Magendie imi)uted th? 



152 



FEVER. 



dcalh of the animal to the effect of the miasmata 
he respired and took with his food. On opening 
the body, which was much emaciated, the mucous 
membrane of the bowels was found inflamed. 

CLASSIFICATION OF FEVERS. 

Pyrexise, or febrile diseases, have been divided 
into two great classes, — Fevers and Inflamma- 
tion's. In the present article, we shall consider 
the first class only, referring the reader for the 
consideration of the second, viz. symptomatic fe- 
vers (inflammations), to the separate articles in 
the work. 

The different forms of fever have received vari- 
ous distinctive appellations, founded onlheir sup- 
posed causes. We accordingly tind in systematic 
works various subdivisions, — camp, hospital, pri- 
son, or Jail fever. Others have preferred, as a 
ground of distinction, the peculiar phenomena 
which each type of the disease presents ; hence 
the origin of the nomenclature, injlammatory, bi- 
lious, nervous, malignant or putrid, petechial, 
typhoid, yellow fever, &c. 

The typos of fever which are met with in tem- 
perate countiies have been arranged according to 
certain phenomena observed in each. In one 
form, the symptoms or series of phenomena con- 
stituting the febrile paroxysm observe a continued 
or uninterrupted course ; in a second, they do not 
follow a continuous course, but become either sus- 
pended for a definite period, or a considerable re- 
mission or abatement only takes place ; in a third, 
the febrile symptoms are accompanied with a pe- 
culiar eruption, which, with certain symptoms, 
indicates a particular form of eruptive or exanthe- 
matous fever. 

A classification of fevers, founded on these dis- 
tinctive characteristics, being sufficient for every 
practical purpose, the following arrangement will 
be adhered to in the present work : — 

1. Continued. 

a. A simple. 

b. Complicated. 

c. Typhus. 

2. Periodic. 

a. Intermittents. 

b. Remittents. 

3. Eruptive, or 
Exanthematous. 

a. Variola. 

b. Rubeola. 

c. Scarlatina. 

Before entering on the consideration of the va- 
rieties of fever, it will be proper to make a few 
observations on the phenomena which occur in a 
febrile paroxysm. The paroxysm consists of three 
stages, — the cold, the hot, and the sweating, which 
in general succeed each other in the order enume- 
rated. 

These terms have been given from the peculiar 
symptoms observed in each stage : thus in the cold 
stage, there is sensation of cold accompanied by 
shaking ; the hot stage is indicated by increased 
heat ; and the sweating stage, by the diaphoresis 
or perspiration which terminates the fit. 

The successive stages which constitute a true 
paroxysm of fever are only observed in intermit- 
tciit fever, in which there is a perfect intermission, 



or apyrexia between the fits. In continued and 
in symptomatic fevers (inflammations), though 
there may be sensible abatement of the febrile 
symptoms at irregular periods, complete suspen- 
sion of the disease for a definite time, as is ob- 
served in periodic fevers, never takes place. Though 
these diseases are often ushered in by a sensation 
of chilliness or actual shivering, almost invariably 
by morbid heat of the skin, still the rigor or cold 
stage is so frequently unobserved, that it cannot 
be said to be essential either to the continued or 
symptomatic forms of fever. 

The first symptoms of the cold stage [or stage of 
concentration] denote a primary impression on the 
nervous system. This is evinced by the disincUna- 
tion to exertion, and the evident feebleness or actual 
prostration. To these succeeds more or less restless 
uneasiness, which induces the patient to endeavour 
to obtain relief by frequent change of posture. This 
restless state is generally accompanied with more or 
less mental inquietude ; hence the inability to fix 
the mind on any subject requiring continued at- 
tention. These are the sensations precursory to 
the rigor or shivering fit, the first indication of 
which is a feeling of chilliness : this may be 
general or only partial ; for instance, it may be 
confined to one or more of the limbs, or to the 
loins, while the other parts of the body feel com- 
fortably warm. The chilliness, after continuing 
some time, passes into tremor, which begins first 
in the lower jaw, and then gradually extending 
over the body, terminates in general muscular agi- 
tation. The tremor is often very severe ; in some 
instances so violent, that according to practitioners 
who have witnessed the more intense forms of 
intermittent fever, convulsions have actually super- 
vened ; this, however, is to be regarded as a rare 
occurrence, at least in temperate climates. The 
skin feels cold, not only to the patient himself, but 
sensibly so to another person ; and when the ther- 
mometer is applied, the temperature is found to be 
many degrees below the average standard of health: 
according to Dr. Wilson Philip, it has been ob- 
served as low as 74° Fahrenheit. 

As the cold stage passes off, the skin becomes 
gradually warmer, though the patient is not always 
sensible of the change ; hence, while he still com- 
plains of feeling cold, the skin often feels comfort- 
ably warm, or even warmer than natural, to an- 
other person. 

The appearance of the skin in the cold stage 
indicates a deficiency of animal heat ; the Ups, 
nails, fingers, and toes, in fact those parts at a dis- 
tance from the centre of the circulation, are pale 
and shrunk, while the skin becomes rough, resem- 
bling that of a fowl after it has been stripped of its 
feathers : hence the term cutis anserina has been 
applied to express this condition of the skin. The 
shrinking of the integuments is exemplified by 
the fact of a ring which fits the finger before the 
approach of the cold stage, becoming so loose as 
to fall off soon after it commences. It is also not 
uncommon for ulcers to dry up, or tumours to 
diminish in size, and even to subside altogether, 
while the cold stage of fever lasts : but when the 
hot stage becomes developed, the finger enlarges, 
so that the ring again fits tight, ulcers again dis- 
charge pus, and tumours re-appear. 

From the intimate sympathy between the ner 



FEVER, (CONTINUED) 



153 



vons and circulating systems, there is in tlie cold 
stage of fever some alteration in the pulse. At 
the very commencement of the fit, before the rigor 
has come on, it is more feeble than natural ; during 
the shivering it is small, quick, and occasionally 
irregular. The breathing is generally at the same 
time hurried, often suspirous, and the patient com- 
plains of tensive pain or constriction in the pre- 
cordial region. 

When this unnatural state of the muscular, circu- 
lating, and respiratory systems has continued for 
some time, the mental functions not unfrequently 
become disturbed, indicated by the restlessness so 
common in almost every kind of fever, by some 
degree of confusion, and sometimes delirium, or 
even coma. In some instances the nervous influence 
of parts at a distance from the brain becomes im- 
paired, as in the instance of some of the senses 
becoming affected, or of the patient complaining 
of a sensation of numbness in the extremities. 

The organs of secretion are at the same time 
more or less deranged. The patient is indifferent 
to food, and complains of thirst and of a disagree- 
able clammy state of the mouth. In some in- 
stances there is gastric disorder, manifested by fre- 
quent retching or vomiting, or purging of bilious 
fluid. This gastric irritation is, however, seldom 
observed in the periodic fevers of temperate coun- 
tries, though in the bilious remittents of hot cli- 
mates it forms a prominent character of the dis- 
ease, and is not unfrequently attended with jaun- 
dice. The urine in the cold stage is limpid. 

The analysis of the symptoms of the cold stage 
of fever proves the consecutive disturbance of the 
nervous, circulating, and secreting systems. It is, 
however, to be remembered that there is great dif- 
ference in the intensity of the affection in the 
several organs ; the prominent characteristic — the 
sense of cold, or even the rigor may be altogether 
wanting, or only represented by a degree of gene- 
ral indisposition, such as languor, chilliness, and 
sense of feebleness. This will be more particu- 
larly pointed out when irregular periodic fevers 
are noticed. 

The duration of the cold stage of fever varies 
from half an hour to four or five hours, but there 
is every intermediate variety as to its length. It 
is often longer in the first than in the subsequent 
paroxysms, and shorter in remittents than in inter- 
mittents; so that, although its average duration 
may be computed between one and two hours, 
much depends on the type of the fever, its sever- 
ity, and tlie climate in which it occurs. It is al- 
ways longer and more severe in warm than in 
temperate countries ; it may even be mitigated 
by the adoption of certain measures to be pointed 
out when we come to notice the treatment ; but 
as a general rule, it has been observed that when 
the cold stage is short, the subsequent stages of 
the fever are almost invariably severe. 

Though there is seldom any danger to be appre- 
hended in the cold stage, it is proper to state, that 
under some circumstances, so great has been the 
shock given to the nervous system, that the vital 
powers have never recovered such a degree of en- 
ergy as to produce re-action; indeed individuals 
have actually died in the cold fit. 

The approach of the hot stage [or stage of ex- 
pansion,] of fever is indicated by the chilliness 

Vol. II 20 



or shivering subsiding, or alternating with warm 
flushings. The natural heat and colour of the 
skin then return, the shrinking and cutaneous 
constriction being succeeded by fullness, especially 
of the features, which in the beginning of the hot 
stage appear more turgid and animated than in 
health. This is followed by increased heat, which 
becomes gradually diffused over the body, the 
thermometer indicating an increase of several de- 
grees above the ordinary average temperature of 
health, (varying from 10()° to 105° Fahrenheit,) 
while the skin feels dry and parched. With these 
external changes, there are corresponding altera- 
tions in the functions of the several organs : for ex- 
ample, the depression, stupor, or coma of the cold 
stage is succeeded by sensibility to external im- 
pressions, so that sounds or brilliant light are 
offensive ; there is generally pain in the head, 
back, and limbs, and not unfrequently transient 
delirium. The breathing becomes more free ; the 
pulse, from being small, feeble, and rapid, becomes 
more full and expanded, and the sense of precor- 
dial constriction, which is so oppressive in the cold 
stage, subsides. In this accelerated state of the 
circulation, hemorrhage from various parts, more 
particularly from the nose, lungs, uterus, or bow- 
els, is not uncommon. These evacuations of 
blood have generally been remarked to be salutary, 
by relieving local congestions, which are apt to 
take place in the hot stage of fever. 

There is little change in the natural functions • 
there is perhaps more thirst ; the urine becomes 
high-coloured, but on standing does not deposit 
any sediment ; and should there have been much 
gastric disturbance during the cold stage, it gene- 
rally abates or goes off entirely as the hot fit be- 
comes developed. 

The hot stage gradually terminates in copious 
perspiration. This constitutes the sweating stage, 
[or stage of termination,] which is generally fol- 
lowed by great relief. The upper parts of the 
body first become bedewed with moisture, the 
sweating afterwards extending over the trunk and 
lower extremities. The sensorial disturbance now 
vanishes, the pulse resumes its natural tranquillity, 
the breathing becomes easy, and the urine in many 
instances deposits a sediment some time after it 
has been voided. The sweating, after continuing 
some time, disappears, but the patient remains 
weak and exhausted after the paroxysm has quite 
disappeared. 

Though these three stages occur in regular 
progression in every well-marked paroxysm of 
periodic fever, there is great diversity in the in- 
tensity and duration of each paroxysm as well 
as of its several stages, as will be fully illustrated 
when the different forms of periodic fevers are 
treated of. 

FEVER, CONTINUED. — The division of 
fever which, according to the proposed arrange- 
ment, comes first under consideration, is the con- 
tinued. This class of fevers has been so termed 
from the paroxysms consisting of remissions and 
exacerbations, without intervals of abatement or 
pyrexia, as in the intermittent and remittent types. 

In systems of nosology every variety of con- 
tinued fever is comprehended under the term Sy- 
nochus (from the Greek word cwix'^, to continue.^ 



154 



FEVER, (CONTINUED) 



The milder forms have been termed synochus mi- 
tior; the more intense, synochus gravior ; the 
intensity depending on the various local inflam- 
mations which arise in the progress of the fever. 

1. Simple Fevek. — There is, perhaps, no dis- 
ease in which the premonitory symptoms are so 
diversified as those of fever ; this is owing to the 
general resemblance observed in the commence- 
ment of every febrile disturbance, whether idiopa- 
thic or symptomatic ; and it is not unlil the symp- 
toms have continued for some time that the prac- 
titioner can discriminate the precise nature of the 
iisease. 

In idiopathic fever there is generally a period 
A undefined indisposition, evinced by disinclina- 
don to mental exertion : the individual is incapa- 
citated from any ordinary mental effort; his percep- 
tions are less clear and distinct than usual. To 
this condition of the mental powers the term lan- 
guor is applied, and it is always an indication of 
he commencement of febrile action. A sensation 
)f lassitude or diminution of muscular vigour is 
lext felt ; the patient feels fatigued and averse to 
anv kind of exertion ; if he attempt to walk, his 
movements are feebly or unsteadily executed. 
The muscles soon become unai>le to support the 
weight of the body ; hence the recumbent posture 
is not only most easy, but indispensable. Boer- 
haave first applied the characteristic term debilitai- 
febrilis to this state of the muscular system in 
fever. The alteration in the expression of the 
countenance, so marked in fever, is probably inti- 
mately associated with this condition of the mus- 
cular system, and forms a diagnostic of great value 
to the experienced practitioner, not only of the 
nature of the disease, but of the various changes 
which take place in its progress. It is difficult to 
give in words an idea of the febrile countenance: 
there is a look of anxiety, denoting much inward 
distress ; the features are pale and sharp ; and the 
whole expression is so changed as at once to alter 
the character of the countenance : hence the fa- 
vourable impression which is always taken from 
any improvement in the aspect of the features. 

Irregular chills and sometimes shivering come 
on ; but more generally there are alternate fits of 
heat and cold of short duration, which continue 
to recur at intervals, even when the skin is hotter 
than natural; and it will be observed that during 
the time the patient complains of chilliness, the 
skin does not feel cold to another person, nor does 
the thermometer indicate any diminution of tem- 
perature. It appears, therefore, that the coldness 
is produced by some cause within the system it- 
self, and is by no means to be attributed to exter- 
nal temperature, as it is observed in hot as well 
as in cold climates, and to recur when every pre- 
caution has been adopted with respect to the tem- 
perature of the apartment and the clothing of the 
patient. 

About this period there is great restlessness, and 
uneasiness of an undefined and indescribable 
nature, which, after a short time, is succeeded by 
pain in the loins and extremities, with feeling of 
getieral soreness. 

These symptoms, denoting the first stage of 
fever, are succeeded by those indicating re-action. 
The face becomes flushed, and the heat over the 
surface is steadily and uniformly above the natural 



temperature, varying from 100° to 105° Fahren- 
heit. The heat on some parts of the body is per. 
ceptibly greater than on others ; hence, in those 
irregular accessions which take place, the increase 
is chiefly percejitible in the flice, hands, and feet. 
Sometimes, on the other hand, there is no increase 
of the animal heat in fever ; the skin throughout 
the course of the disease retaining its natural 
temperature, or in some cases falling even below 
it: such deviations are always to be regarded as 
unfavourable, though, as physiology has not yet 
discovered the source of animal heat, we areigno- 
rant of the causes on which they depend. 

If the circulation be now examined, the pulse, 
which at the beginning is oppressed, will be found 
quick, seldom, however, exceeding 100°. Besides 
increased frequency, it may have acquired other 
characters ; it may be quick and soft, or full and 
strong, seldom, however, hard or tense. It occa- 
sionally, though very rarely, happens that the pulse 
does not, during the progress of fever, vary from 
its natural condition either as to frequency or 
power, and even when the other sym[)t()ms are 
well marked. A similar anomaly has just been 
pointed out as to the heat of the skin, which now 
and then does not exceed, or even falls below the 
natural temperature. 

Though the function of respiration is not neces- 
sarily involved in fever, still, when the febrile ex- 
citement is considerable, the breathing bcconieo 
hurried. This condition must be distinguished 
from that which depends on some inflammatory 
condition of the lungs. The absence of cough 
in the one instance, and its almost invariable pre- 
sence in the other, with the sounds elicited by 
auscultation, will tend materially to aid the practi- 
tioner in forming a proper judgment of this symp- 
tom. It should also be kept in view that in those 
forms of fevpi in which the brain is severely 
affected, the breathing becomes embarrassed. It 
is sometimes short and quick, or slow and inter- 
rupted. In these cases the state of the breathing 
is the effect of the disturbance in the brain, and 
not of pulmonary disease. 

When the fever has thus become developed, the 
primary disturbance of the brain is succeeded by 
symptoms vi'bich indicate increased action in the 
cerebral vessels. This is indicated by headach; 
the pain being in some instances confined to the 
forehead, sometimes to the occiput. It varies in 
intensity as well as duration, but is always 
increased on any movement of the body, or any 
circumstance which excites the circulation. In 
many instances of the mild forms of fever, how- 
ever, the patient never experiences headach ; he 
complains only of giddiness or of a sense of 
heaviness or weight, particularly in the occiput. 
It is not easy to explain the cause of these differ- 
ences in sensation, but it is important to bear in 
mind, that they all depend on one and the same 
condition of the brain, and require similar though 
perhai)s modified treatment. 

As the disease proceeds, the languor and lassi- 
tude of the first stage give place to sensorial dis- 
turbance, indicated by great restlessness and irrita- 
bility, and sometimes slight delirium towards 
evening, which abates or totally disappears in the 
morning. 

The various senses are more or less disturoed; 



FEVER, (CONTINUED) 



155 



the hearing is often morbidly acute, so that even 
slight sounds give uneasiness if not pain ; some- 
times it is dull and obtuse; the sense of smell is 
vitiated ; the taste is so altered that common articles 
of (^iet are scarcely recognised, and there is gene- 
rally great aversion or loathing of food ; the mouth 
is clammy ; the tongue covered with thin white 
fur ; and there is more or less thirst. 

The excretions are altered, both as to quantity 
and quality ; the urine is high-coloured and tur- 
bid, or deposits a sediment on standing ; and the 
evacuations from the bowels are generally of an 
unhealthy character. 

The fever is now said to be fully formed, or, in 
popular language, to be at " its height." In the 
majority of cases, towards the evening, or in some 
instances at irregular intervals, there is an exacer- 
bation, or general increase of the febrile excite- 
ment, which abates towards the morning. The 
accession is indicated by greater restlessness, by 
the skin becoming more hot, the face more flushed, 
and by increased thirst and frequency of pulse. It 
is probably in consequence of the increased velo- 
city of the circulation through all the organs, and 
consequently in the brain, during these exacer- 
bations, that the patient is so much more restless 
and indisposed to sleep ; and hence it is that, 
when there is disposition to congestion or inflam- 
mation in any organ, it is often developed at these 
periods. 

With regard to the duration of simple fever, 
the symptoms may continue without any particu- 
lar change for a few days ; but its limitation de- 
pends on a variety of circumstances. It may last 
only one day, and this constitutes the common 
ephemerul fever, which terminates in twenty-four 
hours ; a form to which women in childbed, from 
a variety of causes, are occasionally suliject : or it 
may go on for an uncertain number of days, or 
even weeks, terminating, however, in the majority 
of instances, about the end of the second or begin- 
ning of the third week. It not unfrequently happens 
that its duration is materially diminished by some 
spontaneous evacuation ; either by the skin or 
bowels, or perhaps by some accidental hemorrhage; 
or without such Spontaneous efibrts of the system, 
by moderate venesection, if the febrile excitement 
require the loss of blood, or in milder cases, by 
purging, confinement to bed, and the adoption of 
a mild farinaceous diet. 

The ancients, who accurately observed the phe- 
nomcria and progress of fever, remarked that the 
sympioms showed a tendency to abate at regular 
periods, which were called critical days. This 
crisis was observed to occur on the third, seventh, 
fourteenth and twenty-first days from the com- 
mencement of the symptoms, or first invasion of 
the disease. If the symptoms passed over the 
first period, those who gave credence to this doc- 
trine predicted, that the fever would go on to the 
second or beyond it; for example, if the symptoms 
did not abate on the seventh, that the fever would 
not tormiriale till the fourteenth day; if this day 
were exceeded, that it would run on to the twenty- 
first, and so on. 

Modern physicians place very little confidence 
in this restricted duration of fever. The ancients, 
being afraid of interfering in any way with the 
eflforts of nature to get rid of what they supposed 



hurtful to the system, considered every kind of 
treatment improper, and were, therefore, more 
likely to observe, in the milder forms of fever, an 
abatement by crisis on particular days. The mo- 
dern treatment of the disease, founded on more 
just views of its pathology or nature, is very likely 
to interrupt or disturb such regular periods of de- 
cline ; and therefore, though the doctrine of criti- 
cal days is not in our day altogether exploded, 
practitioners are either less inclined to look for 
them, or to reject the idea as not according with 
nature. Besides, in fever complicated with local 
inflammation, such regularity in the crisis cannot 
be expected to occur; the symptoms depending in 
some measure on the condition of the organ, which 
may, in the progress of ihe disease, have become 
inflamed. It cannot, however, be doubted that 
the notion of critical days was originally founded 
on correct observation, that fevers are disposed to 
terminate favourably or unfavourably at certain 
periods ; and though such critical termination can- 
not in every, or even in the majority of instances, 
be discerned or traced, the fact, that simple or un- 
complicated cases occasionally do so, should al- 
ways be kept in view. 

The convalescence, or period of the decline of 
fever is observed to be gradual ; the feelings of the 
patient improve, his countenance becomes ani- 
mated, and its expression so altered, that except 
by those who are acquainted with the previous 
aspect of the countenance, the ii ;lividual would 
not be recognised — the sleep becomes longer and 
more refreshing — the pulse comes down gradually 
till it returns to its natural frequency — the skin 
becomes cool — the tongue clean, the appetite for 
food returns — the thirst ceases, and the strength 
and spirits improve. These favourable changes 
indicate the stage of convalescence, which is con- 
firmed in a few days under proper management, 
especially if great attention be paid to the regula- 
tion of diet, and avoiding undue bodily or mental 
fatigue. No consideration should induce the 
practitioner to relax in hrs close attendance during 
this most important, but too often neglected peiiod 
of the disease. 

The description now given applies to the mild 
epidemic fever of this and other temperate cli- 
mates. It is almost unnecessary to s<ate, that 
there is every gradation not only in the intensity, 
but in the duration of the symptoms. The symp- 
toms may be so mild as scarcely to require more 
than an aperient, quietude, and abstinence; or 
they may assume a severe character, — the fever 
passing into some of the other forms to be after- 
wards described. 

Inflammatory Fever. — A variety of conti 
nued fever of a hypcr-acute form is occasionally 
observed, and, though not very common in tempe- 
rate climates, it does now and then occur, and re- 
quires notice. It has been called ''"ilannnatory 
fever (synocha), and may occur at all ages and in 
all habits, forming the general character of fever 
in young and plethoric subjects, who have great 
muscular power and corresponding vigorous cir- 
culation. When it occurs in cold and temperate 
countries, it is distinguished fiom simple fever 
(synochus) by its more sudden invasion, — by the 
more pungent heat of the skin, flushing of the face, 
suffusion of the eyes and intolerance of light 



156 



more intense headach, throbbing of the carotid and 
temporal arteries, watchfuhiess, and delirium. The 
pulse is seldom very rapid at first, but as the dis- 
ease proceeds, it becomes full, round, and tense, 
but never remarkably frequent, and the blood after 
venesection generally exhibits the buflfy coat. 
The breathing is quick, the thirst incessant, and 
the febrile restlessness distressing. In some in- 
stances, there are nausea and vomiting, with pain 
in the epigastrium, stretching to either hypochon- 
drium, more especially if this form occur in the 
summer and autumn months in warm climates, 
where it is generally termed bilious or bilious in- 
flammatory fever. When inflammatory fever be- 
comes fully developed, spontaneous hemorrhage 
not unfrequently occurs ; if it proceed from the 
nose, it generally affords great relief to the symp- 
toms, on which account it should not be interfered 
with, unless it produces feelings of exhaustion. 

From the violence of the general excitement in 
inflammatory fever, local inflammations are ex- 
ceedingly apt to intervene. It may also pass into 
other forms : we accordingly find that in warm 
climates, more especially in the West Indies and 
some districts of the United States, it assumes 
very often the remittent t3rpe, or it may lapse into 
a low kind of typhoid fever. 

Its duration varies according to circumstances. 
It now and then assumes an ephemeral character, 
— disappearing in twenty-four hours : mild cases 
of longer duration by proper management may 
pass olf in a few days ; but if the symptoms he 
neglected in the commencement, the fever may 
last two or three weeks or longer, and then gra- 
dually subside, the symptoms losing their acute 
character as the disease advances. 

It is proper, however, to state that in our expe- 
rience of the epidemic fever of this country, this 
form, (synocha,) if it really do occur, has been 
seldom observed. A few sporadic cases, which 
have many of the essential characters detailed, 
certainly present themselves occasionally in the 
spring months ; but these form a comparatively 
small average proportion of the ordinary fever of 
Britain. It is, therefore, to the fevers which occur 
in warm climates that the description given more 
particularly applies ; the character of fever, as 
will be afterwards explained, being materially in- 
fluenced by climate and season. It is also neces- 
sary to bear in mind the local inflammations 
which almost invariably arise in the course of 
these acute fevers, and the effect of such compli- 
cations on the febrile symptoms. 

Gastric Fever. — When the S3'mptoms of 
common fever are attended with more than ordi- 
nary gastric derangement, the term gastric fever 
has been applied. Hippocrates, with his charac- 
teristic discernment, evidently alludes to this va- 
riety of fever, in treating of acute diseases with 
heat and biliary dejections ,- and Galen, the first 
writer who distinguished fevers into sanguineous 
and bilious, founded his idea of the latter on the 
condition of the stools. This form of fever has in 
later times been called by different names. Baillou 
first termed it gastric fever; Hoffmann, the cho- 
leric; 'B2ig\W\, \.\\& mesenteric ; John Peter Frank, 
fehrv^ continua gastrica; Pinel, the meningo- 
gastric. 

Pisorder in the alimentary canal gives rise, not 



FEVER, (CONTINUED; 



unfrequently, to fever of a particular form. In 
other instances, sym[)toms of gastric disorder may 
supervene on common fever ; in either case, the 
train of symptoms, which are very much alike, 
and require a similar mode of treatment, are in 
the one case the cause, in the other, an accidental 
accompaniment of the fever. 

Gastric fever may occur sporadically ; at other 
times the gastric symptoms form the prominent 
type of an epidemic; and from its prevailing in 
the summer and autumn months after very hot 
weather, it would seem to be produced by some 
atmospheric or terrestrial emanations peculiar to 
this season of the year. There are several ac- 
counts on record of epidemic gastric fever ; indeed, 
the fevers of Britain towards the end of summer 
and in the autumn are almost uniformly accom- 
panied with gastric irritation, and from our indi- 
vidual experience of the character of fever for the 
two preceding years (1830 and 1831,) we can 
affirm that an unusual degree of gastric disorder 
has accompanied the disease during the whole of 
that period. The type of the fever has moreover 
been low and typhoid to a degree which has not 
been witnessed for many years preceding, so much 
so as to preclude the employment of evacuations 
of iciny kind, and to render stimuli necessary to an 
extent very unusual in the London Fever Hos- 
pital. 

From a communication with which we were 
lately favoured by our friend Dr. Brown of Sun- 
derland, it appears that a similar type of fever 
preceded the late visitation of cholera in the north 
of England. This fact, with the similarity of the 
symptoms of epidemic fever in those situations in 
which cholera has hitherto appeared, renders it 
probable that some peculiar condition of the at- 
mosphere has given a tendency to gastric disorder, 
not only in fever but in other acute diseases. It 
is a singular circumstance, also, that when cholera 
appeared in London, epidemic fever sensibly di- 
minished both in frequency and severity, while 
the gastric irritation and prostration of strength, 
which formed the prominent features of fever, 
have also nearly subsided. 

In gastric fever there is great variety in the 
mode of attack and sutferings of the patient. In 
some cases there is so little evidence of illness 
that the patient follows his ordinary pursuits, 
thinking he is only indisposed from derangement 
of stomach, till the prostration of strength and the 
gradual accession of febrile symptoms show evi- 
dently the nature of the disease. In other cases 
the symptoms from the beginning are so well 
marked, as to leave little doubt of their nature 
and tendency. 

The precursory symptoms are very similar to 
those of other forms of fever — sense of chilliness, 
rigors, irregular flushes of heat, languor, las- 
situde, pain in the head, loins, and extremities. 
The face is pale and sallow, the conjunctiva yel- 
low; the mouth clammy and bitter, the breath fe- 
tid ; the tongue at first is slightly coaled with thin 
white or grey fur, which increases in thickness, 
becoming yellow over the body and root, while the 
pomt and edges are red : in other cases, it is clean 
and morbidly red from the beginning. 

More or less disturbance of the stomach is ob- 
served early in the disease ; there is pain or s«>nse 



FEVER, (CONTINUED) 



157 



of weight or distension in the epigastrium ; often 
nausea and retchins^, which generally ends in vo- 
miting of bilious fluid : the state of bowels is vari- 
able ; there is either constipation alternating with 
diarrhoea, or there is purging from the commence- 
ment, the stools being watery, of a pale green, or 
brownish yellow colour, extremely fetid, and occa- 
sionally mixed with blood. The pulse, which 
from the commencement may not have been much 
accelerated, now becomes rapid ; the breathing 
hurried ; the heat of skin pungent ; the febrile 
uneasiness and general pain increased ; and to- 
wards evening, there is exacerbation of the symp- 
toms, with watchfulness and delirium. As the 
morning advances, however, a distinct remission 
takes place, accompanied with gentle moisture on 
the forehead and chest. The coating on the tongue 
becomes more thick, sometimes dry and brown ; 
and the urine, scanty and passed with pain, de- 
posits a lateritious sediment. 

At a still more advanced period of the disease, 
we observe the morning remissions so slight as to 
be scarcely noticed, while the whole complexion 
of the symptoms becomes aggravated ; the deli- 
rium, which was perhaps only noticed towards 
evening, is constant ; the tongue, palate, and 
throat are more dry, and covered with viscid mu- 
cus, or a dry, hard, black crust envelopes the 
tongue, which is sometimes irregularly fissured 
and covered with aphthse ; the speech and sense of 
hearing are impaired ; the eyes suffused ; the pulse 
is very rapid and compressible ; the evacuations 
are passed unconsciously, with tympanitic disten- 
sion of the abdomen. This congregation of symp- 
toms denotes an intense and advanced form of 
gastric fever, from which the patient not unusually 
perishes, though if the previous powers have been 
vigorous, and the treatment judicious, the patient 
may be recovered. When a favourable termina- 
tion is about to take place, the delirium abates, the 
morning remissions become again distinct and of 
longer duration, the skin cool and soft, the tongue 
and palate moist, the former throwing off its dark 
incrustation and exhibiting the subjacent mucous 
membrane morbidly red and tender; the bowels 
become pungent, the stools more consistent, and 
the abdomen feels soft from the subsidence of the 
tympanitic distension. 

When a fatal termination is about to ensue, 
the yellowness of the eyes, headach, delirium, and 
flushing increase ; the patient, at one time furious, 
becomes drowsy and comatose; the stools, and 
occasionally the urine, bloody and passed involun- 
tarily ; the tongue, tremulous, and, as well as the 
teeth, covered with dry black fur, cannot be pro- 
truded. To these symptoms succeed picking of 
the bed-clothes, starting of the tendons, hiccup, 
rapid breathing, cadaverous smell of the perspira- 
tion and breath, cold sweats, imperceptible pulse, 
and coldness of the extremities. 

It is necessary to state that in gastric as well as 
other forms of fever, local inflammations arise in 
its progress. It is, therefore, important to watch 
the symptoms in the different organs, more par- 
ticularly the brain, which from the inflammatory 
type of the fever at the commencement is often 
severely affected. In like manner the several or- 
gan? in the chest and abdomen may become in- 
flamed, and render the disease formidable. 



Frank states, that in some cases quantities of 
worms are expelled from the stomach and bowels 
during gastric fever. In such instances the febrile 
symptoms are accompanied with thofe peculiar to 
vermination — wandering pains, itching of the 
nose and anus, prominence of the abdomen, vo- 
miting, tenesmus and copious mucous stools. 

The duration of gastric fever is uncertain. 
When the disease is mild, it may not last above a 
week or ten days ; generally, however, it is tedious 
and protracted, more especially if neglected in the 
early stage. It is unnecessary to state that its 
duration will be materially affected by any inflam- 
matory complication with which it may happen to 
be associated. 

The history of epidemic gastric fever, written 
for this work by Dr. Cheyne, gives an admirable 
sketch of this variety of fever ; and we beg par- 
ticularly to call attention to the observations of 
that able physician on this subject. (See Fever, 
Epidemic Gastric) 

2. Complicated Feveh. — In the preceding 
observations it has been our object to show that 
in simple fever the disturbance in the various or- 
gans, however severe, is only functional, no in- 
flammation in any organ having as yet taken place. 

It is necessary, however, that the practitioner 
should bear in mind, that although fever at its 
commencement may be mild, in a large proportion 
of cases it assumes a severe character, in conse- 
quence of some local inflammation arising in its 
progress. Hence, whatever be the primary efiect 
of the exciting causes on the various organs, the 
transition from excitement to inflammation is often 
rapid, more especially when there is predisposition 
to disease in any particular organ. 

From what has been previously advanced, as 
well as from the facts which will be adduced when 
the causes of fever are discussed, there are strong 
grounds for supposing that the febrile poison pro- 
duces a peculiar or specific effect on certain or- 
gans of the body in the first instance. The affec- 
tion thus primarily induced, whatever it may be, 
is not, however, of an inflammatory character, 
though it is evident, both from symptoms observed 
during life, and from morbid appearances after 
death, that inflammation does arise in certain or- 
gans in the progress of fever. If the febrile poison 
be not in a state of great concentration, it may be 
presumed that a peculiar action only is exerted on 
one or more organs; if the poison be in a state of 
greater activity, it would appear to produce se- 
vere organic lesion — inflammation and its conse- 
quences. 

We do not pretend to explain the modus ope- 
randi, or theory of action of the causes alluded 
to; or why, in individuals exposed to the same 
causes, in one case very slight effects, while in 
another the most severe and often fatal symptoms 
are produced. There may be greater aptitude fo> 
the reception of the febrile poison in one persor 
than in another, arising from individual peculiarity 
or idiosyncrasy, as it has been termed. 

This tendency of the primary febrile affection 
to pass into inflammation, which local inflamma- 
tion is the cause of the severity in the majority 
of cases of fever, should never be overlooked. Il 
is equally important to bear in mind that the 
inflammatory action which supervenes, is of 3 



158 



FEVER, (CONTINUED) 



loss intense kind than in the ordinary phlegm- 
asia. 

There are few organs in the body which are 
not occasionally affected in fever. Some, how- 
ever, suffer more uniform and severe lesion than 
others ; as, for instance, the brain and spinal mar- 
row, the mucous membrane of the lungs, and of 
the alimentary canal. Inflammation of the paren- 
chyma of organs is occasionally, though less fre- 
quently, observed. 

Cerebral complication, — From the almost in- 
variable disturbance in the brain and nervous sys- 
tem in fever, it is particularly necessary to watch 
any tendency to transition from functional disor- 
der to inflammation of the brain. Not only the 
symptoms during life, but the morbid appearances 
discovered after death prove that inflammation of 
the membranes of the brain is by far the most 
frequent and dangerous of the local inflammations 
that occur in the progress of fever. 

The cerebral affection assumes various degrees 
of intensity. In some cases it is mild, in others 
severe ; and between these extremes there is every 
intermediate modification. Sometimes the cere- 
bral affection appears in solitary instances during 
a mild epidemic, or it may form the prominent 
character of epidemic fever. 

If the symptoms be attended to, it is impossible 
to overlook the first indications of acute affection 
of the brain in fever. The general symptoms 
may at first be little urgent, and proceed as has 
been stated in the history of mild fever. The 
patient, however, is afterwards observed to com- 
plain of more constant and severe pain in the 
head, accompanied with throbbing of the carotid 
and temporal arteries, flushing of the face, and 
heat of the scalp. In general the pain is confined 
to a particular part, very often to the forehead and 
temples, occasionally shooting to the occiput ; at 
other times it is felt chiefly in the back of the 
head. 

In many instances the cerebral inflammation is 
not indicated by pain, but by giddiness. Even if 
the head be shaken, or suddenly moved, no pain 
is induced, though the giddiness and flushing are 
increased. Moreover, when pain in the head has 
existed, it is often of short duration ; but, not- 
withstanding it has ceased, the local affection may 
be proceeding with equal, if not increased vigour, 
and, if not arrested, may speedily destroy life. 
The absence of pain in such cases, therefore, must 
not be aUowed to throw the practitioner off his 
guard ; he must be guided in his opinion of the 
condition of the brnin by the presence of other 
equally pathognomonic signs. Thus the eyes are 
brilliant or suffused, their expression either mor- 
bidly animated or dull, but generally sensible to 
light ; hence the contracted eyebrows, half-closed 
eyelids, and the relief experienced from a dark 
loom. 

T